Hemorrhoids refer to a common anorectal disorder that is usually associated with vascular proliferation. The present study investigated the role of miR-143-3p in the development of hemorrhoids and postoperative wound healing, aiming to provide novel ideas for the study of the pathogenesis of hemorrhoids and their clinical treatment.

Hemorrhoid tissues and normal perianal tissues were collected from 42 patients who underwent hemorrhoid surgery. The expressions of miR-143-3p, vascular endothelial markers (CD31, vWF, and VEGFR2), and inflammatory factors (TNF-α, IL-1β, and IL-6) in these tissues were determined using RT-qPCR. The correlation of miR-143-3p with CD31, vWF, and VEGFR2 was analyzed using Pearson's method. The proliferation of HUVEC and HaCaT cells was detected using the CCK-8 assay. The migration of HUVEC and HaCaT cells was detected using Transwell assay. The apoptosis of HUVEC cells was detected using flow cytometry.

Reduced expression of miR-143-3p in hemorrhoid tissues was negatively correlated to the mRNA levels of CD31, vWF, and VEGFR2. The mRNA levels of CD31, vWF, and VEGFR2 in the HUVEC cells were reduced after miR-143-3p overexpression. Overexpression of miR-143-3p inhibited the proliferation and migration of HUVEC cells while promoting apoptosis in these cells. Upregulation of miR-143-3p decreased the mRNA levels of TNF-α, IL-1β, and IL-6 in HaCaT cells while promoting cell proliferation and migration in these cells.

Downregulation of miR-143-3p was noted in hemorrhoids, which could be linked to the regulation of angiogenesis. MiR-143-3p might have an anti-inflammatory role in postoperative wound healing.

The optimal management strategy for grade III hemorrhoids remains a subject of ongoing debate. Hemorrhoidectomy is the criterion standard, but rubber band ligation offers a less invasive outpatient alternative. Treatment variability persists due to a lack of consensus on the preferred strategy.

To directly compare the effectiveness of rubber band ligation and hemorrhoidectomy in the treatment of grade III hemorrhoids.

Open-label, parallel-group, randomized controlled noninferiority trial.

Multicenter study across 10 Dutch hospitals from October 2019 to September 2022.

Patients (aged 18 years or older) with symptomatic grade III (Goligher) hemorrhoids were included in this study. Exclusion criteria included prior rectal/anal surgery, more than 1 rubber band ligation/injection within the preceding 3 years, rectal radiation, preexisting sphincter injury, IBD, medical unfitness for surgery (ASA higher than 3), pregnancy, or hypercoagulability disorders.

Randomized 1:1 to rubber band ligation or hemorrhoidectomy, with up to 2 banding sessions allowed.

Primary outcomes included 12-month health-related quality of life and recurrence rate. Secondary outcomes included complications, pain, work resumption, and patient-reported outcome measures.

Eighty-seven patients were randomly assigned (47 rubber band ligation vs 40 hemorrhoidectomy). Rubber band ligation was not noninferior to hemorrhoidectomy in quality-adjusted life years (-0.045; 95% CI, -0.087 to -0.004). Recurrence rate was worse in the rubber band ligation group (47.5% vs 6.1%), with an absolute risk difference of 41% (95% CI, 24%-59%). Complication rates were comparable. Pain scores after hemorrhoidectomy were higher during the first week (visual analogue scale 4 vs 1; p = 0.002). Rubber band ligation group returned to work sooner (1 vs 9 days; p = 0.021). Patient-reported hemorrhoidal symptom scores favored hemorrhoidectomy.

The primary limitation of the study was its early termination due to funding constraints, resulting in a relatively small sample size and limited statistical power. Patient recruitment was hindered by significant treatment preferences and the COVID-19 pandemic.

Hemorrhoidectomy may benefit patients with grade III hemorrhoids in terms of quality of life, recurrence risk, and symptom burden, whereas rubber band ligation allows faster recovery with less pain. These findings can guide clinical decision-making. See Video Abstract .

NCT04621695.

ANTECEDENTES:La estrategia óptima de tratamiento para las hemorroides grado III sigue siendo un tema de debate continuo. La hemorroidectomía es el estándar de oro, pero la ligadura con banda elástica ofrece una alternativa ambulatoria menos invasiva. La variabilidad del tratamiento persiste debido a la falta de consenso sobre la estrategia preferida.OBJETIVO:Comparar directamente la eficacia de la ligadura con banda elástica y la hemorroidectomía en el tratamiento de las hemorroides grado III.DISEÑO:Ensayo de no inferioridad, controlado, aleatorizado, de grupos paralelos y abierto.ENTORNO CLINICO:Estudio multicéntrico en 10 hospitales holandeses desde octubre de 2019 hasta septiembre de 2022.PACIENTES:Pacientes (≥18 años) con hemorroides sintomáticas grado III (Goligher). Exclusiones: cirugía rectal/anal previa, >1 ligadura con banda elástica/inyección en los tres años anteriores, radiación rectal, lesión preexistente del esfínter, enfermedad inflamatoria intestinal, incapacidad médica para la cirugía (ASA >3), embarazo o trastornos de hipercoagulabilidad.INTERVENCIONES:Aleatorización 1:1 para ligadura con banda elástica o hemorroidectomía, con hasta dos sesiones de ligadura permitidas.PRINCIPALES MEDIDAS DE RESULTADOS:Primarias: calidad de vida relacionada con la salud a los 12 meses y tasa de recurrencia. Secundarias: complicaciones, dolor, reanudación del trabajo y medidas de resultados informadas por el paciente.RESULTADOS:Se aleatorizaron ochenta y siete pacientes (47 ligadura con banda elástica frente a 40 hemorroidectomía). La ligadura con banda elástica no fue no inferior a la hemorroidectomía en años de vida ajustados por calidad (-0,045, intervalo de confianza del 95 %: -0,087 a -0,004). La tasa de recurrencia fue peor en el grupo de ligadura con banda elástica (47,5 % frente a 6,1 %), con una diferencia de riesgo absoluto del 41 % (intervalo de confianza del 95 %: 24 %-59 %). Las tasas de complicaciones fueron comparables. Las puntuaciones de dolor posthemorroidectomía fueron más altas durante la primera semana (escala analógica visual 4 frente a 1; p = 0,002). El grupo de ligadura con banda elástica volvió al trabajo antes (1 frente a 9 días; p = 0,021). Las puntuaciones de síntomas hemorroidales notificadas por los pacientes favorecieron a la hemorroidectomía.LIMITACIONES:La principal limitación del estudio fue su finalización temprana debido a las limitaciones de financiación, lo que dio lugar a un tamaño de muestra relativamente pequeño y a un poder estadístico limitado. El reclutamiento de pacientes se vio obstaculizado por las preferencias significativas de tratamiento y la pandemia de COVID-19.CONCLUSIONES:La hemorroidectomía puede beneficiar a los pacientes con hemorroides de grado III en términos de calidad de vida, riesgo de recurrencia y carga de síntomas, mientras que la ligadura con banda elástica permite una recuperación más rápida con menos dolor. Estos hallazgos pueden orientar la toma de decisiones clínicas. (Traducción- Dr. Francisco M. Abarca-Rendon )NÚMERO DE REGISTRO DEL ENSAYO CLÍNICO:NCT04621695.

This study aimed to evaluate the efficacy and the safety of Doppler-guided hemorrhoid artery ligation (DG-HAL) and tissue-selecting technique (TST) in patients with grade III/IV hemorrhoids. We conducted a retrospective analysis of 251 patients with grade III/IV hemorrhoids between January 2019 and January 2021. Among them, 119 patients had received TST, and the remaining 132 patients received DG-HAL. We collected and compared clinical characteristics of both groups, including post-operative visual analog scale (VAS) for pain, post-operative bleeding, post-operative defecation, urinary retention, and recurrence rate (prolapse and bleeding). The VAS pain score of the first post-operative defecation and at the post-operative day (POD)1 and 2 for the DG-HAL group was lower than those for the TST group (P = 0.006 and P = 0.029). The incidence of post-operative complications (including bleeding, urinary retention and sensation of rectal tenesmus) in the DG-HAL group was lower than that in the TST group (P = 0.021, P = 0.035 and P = 0.047). At follow-up by telephone or outpatient 3 years after surgery, the recurrence rate (prolapse) was lower in the TST group than in the DG-HAL group (P = 0.013). Subgroup analysis showed a higher prolapse recurrence rate in grade IV patients than grade III patients after DG-HAL (P = 0.013). DG-HAL had fewer complications, lower bleeding rates, and less early post-operative pain but showed a higher recurrence rate than TST at the 3-year follow-up, especially in grade IV patients.

Excisional haemorrhoidectomy remains the gold-standard treatment for grade III-IV haemorrhoids owing to the high success rate. However, post-operative pain management is an ongoing challenge. Botulinum toxin injection is thought to improve pain by targeting the internal anal sphincter spasm which occurs following haemorrhoidectomy. This systematic review and meta-analysis examines the effects of concurrent botulinum toxin injection on post-haemorrhoidectomy pain.

A search of MEDLINE, EMBASE and Cochrane Databases for randomised controlled trials (RCTs) of botulinum toxin injection compared with placebo for management of post-haemorrhoidectomy pain was conducted following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Outcomes assessed included daily post-operative pain scores assessed using an analogue scale (0-10), pain at first defecation, analgesia use, complication rates and time to return to work.

A total of seven RCTs assessing 340 patients who underwent an excisional haemorrhoidectomy were included. In total, seven studies (n = 340) found significant reduction in pain post-procedure with botulinum toxin use on day 1 (mean difference, MD -1.53; 95% confidence intervals, CI -2.12, -0.94; p < 0.00001), with similar findings on day 2 and 4 (MD -1.84, 95% CI -3.28, -0.41; p = 0.01 and MD -1.63, 95% CI -2.15, -1.09; p < 0.00001, respectively). However, the analgesic effects were not seen on subsequent analyses up to day 14. Botulinum toxin was seen to be safe, with no significant difference in faecal incontinence (MD 1.05, 95% CI 0.40, 2.75; p = 0.93) or urinary retention (MD 0.37, 95% CI 0.09, 1.53; p = 0.17).

Botulinum toxin use for pain relief post-excisional haemorrhoidectomy is safe and effective in the initial peri-operative period; however, the results were short-lived. Further, more robust randomised controlled trials are needed to strengthen these findings and determine the utility of botulinum toxin in this setting.

PROSPERO Register for Systematic Reviews Registration Number - CRD42024541351 on April 29 2024.

Hemorrhoidal disease (HD) is a public health problem in our clinics and in the quality of life of patients, therefore it is necessary to analyze the actions in the management of HD by healthcare professionals in Spain.

Observational, descriptive and cross-sectional study with data collection through a 28-question survey using a Google® form. 240 surveys were received. Quantitative variables were represented with means and standard deviation and qualitative variables with percentages.

Two hundred and forty surveys were analyzed. Sixty-five percent of respondents were women, with a mean age of 48±12years. Ninety-three percent of the professionals had 21-30years of clinical experience, with more than 70% being family physicians. Fifty-nine percent considered that HD is adequately diagnosed in primary care, but there was a negative impact on follow-up during the COVID-19 pandemic, as 90% considered it inadequate. Forty-two percent of participants were not familiar with the Goligher classification, while 20% knew it and used it in their practice. The most commonly prescribed combination was the use of topical corticosteroids, bulk-forming laxatives, phlebotonics or venoactive drugs, and non-pharmacological measures (12.1%), with diosmin/hesperidin being the most prescribed venoactive agent (63%). Thirty-nine point six percent stated that HD is undertreated. Eighty-nine percent of physicians acknowledged not using any algorithm or protocol for the diagnosis, treatment, and follow-up of HD in their practice, and 89% stated that they were not trained in their workplaces. Seventy-five percent of doctors believed that one of the main limitations hindering the follow-up of the disease was the lack of time during consultations.

Approximately 3 out of 5 professionals believe they adequately manage HD, and only 1 out of 5 respondents acknowledge knowing and using the Goligher classification in their clinical practice. Furthermore, 2 out of 5 assert that HD is undertreated in primary care. The prescription patterns for HD are heterogeneous, involving multiple combinations. The vast majority of professionals do not follow any established protocol for managing the disease. The survey highlights the need for training our professionals in the diagnosis, treatment, and follow-up of HD to ensure that our patients receive the highest possible quality of healthcare.

To develop and implement an evidence-based perioperative health education program for patients undergoing daytime anorectal surgery, and to enhance patients' knowledge scores pertaining to anorectal diseases.

An evidence-based quality improvement project.

Adhering to the evidence-based practice model of the Joanna Briggs Institute, we developed 17 audit criteria grounded in the best available evidence. This evidence-based practice was subsequently applied to patients scheduled for daytime anorectal surgery between March 2023 and May 2024. The project progressed through three distinct phases: a baseline audit, implementation of practice changes, and a post evidence application audit. Specifically, we compared the execution rates of the audit criteria by the nursing staff, patients' scores on anorectal disease knowledge, patient satisfaction, and incidence of postoperative complications before and after implementation of the evidence-based practice.

After implementation of the evidence-based practice, there was a statistically significant difference in the execution rates of audit indicators 1, 2, 5, 6, 8, and 10 to 17 (P < .05). After implementation, patients' average score on anorectal disease knowledge was 74.14 ± 14.40, higher than the average baseline audit phase score of 63.67 ± 12.31 (P = .004). Patients were likely to recommend the hospital's daytime anorectal surgery to others (P = .036). There were no statistically significant differences in patient satisfaction scores or complication incidence between the two groups.

Current evidence suggests that the program may regulate nurse behavior, enhance patients' health knowledge, and improve patients' overall medical experience. Continuous quality supervision and audit should be further conducted in the future.

This systematic review investigates the outcomes of rubber band ligation (RBL) vs. hemorrhoidal artery ligation (HAL) for second and third-degree hemorrhoids. This review was designed, performed, and reported as per the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Literature databases, including PubMed, Cochrane, Science Direct, and Google Scholar, were searched for studies comparing rubber band ligation vs. hemorrhoidal artery ligation for second- and third-degree hemorrhoids. The primary outcome was the recurrence of hemorrhoids, while post-operative bleeding, post-operative pain, surgical site infection, and success rate were the secondary outcomes. The literature search and inclusion criteria identified five studies (n=953) comparing HAL (n=548) vs. RBL (n=405). The recurrence rate was higher in the RBL group (28.4%) compared to the HAL group (19.3%) (odds ratio {OR}: 0.57, p=0.001). The two groups showed comparable results regarding post-operative pain (OR: 0.77, p=0.77), post-operative bleeding (OR: 1.48, p=0.44), and surgical site infection (risk difference: 0.00, p=0.67). Moreover, the short-term success rate was 85% in HAL compared to 86% in RBL (p=0.71). Rubber band ligation and hemorrhoidal artery ligation showed comparable short-term outcomes regarding symptom treatment, post-operative bleeding, and pain. However, HAL was superior in terms of recurrence rate.

Electronic bidets can be a substitute for sitz baths, but no study has examined the use of electronic bidets to manage anal problems.

A randomized, controlled, single-blind, multicenter, parallel group trial was performed. Patients who underwent hemorrhoidectomy were randomly assigned (1:1) to use the electronic bidet or warm sitz baths for 7 days after hemorrhoidectomy. The primary endpoint was the difference in the anal pain VAS score for 7 days posthemorrhoidectomy.

Patients were assigned to the electronic bidet (51) or sitz bath (50) groups. Twenty-six patients dropped out after randomization, and the final analysis included 34 patients in the electronic bidet group and 41 in the sitz bath group. The VAS score for anal pain 7 days posthemorrhoidectomy did not differ between the electronic bidet and sitz bath groups (38.3 ± 21.9 vs. 42.0 ± 21.1, p = 0.453). The upper limit of the 95% confidence interval of the VAS score in the electronic bidet group (81.22) was greater than the margin of noninferiority (46.20).

The VAS scores after hemorrhoidectomy did not differ between the electronic bidet and sitz bath groups, but the noninferiority of the electronic bidet to sitz baths for anal pain 7 days posthemorrhoidectomy was not verified.

The trial was registered on ClinicalTrials.gov (Registration number: NCT02353156, date: 02/02/2015).

In the study, we comment on the article by Qu et al. Internal hemorrhoids are the most common anorectal disorders worldwide with bleeding, prolapse, and difficulty in defecation. Endoscopic rubber band ligation (ERBL) is a safe, convenient, quick, and economical outpatient procedure. The main goal of ERBL is to alleviate prolapse, but the high incidence of recurrence and post-procedural pain are of clinical concern. Polidocanol foam as a local hemostatic and anesthetic agent could reduce the rates of post-procedural pain and bleeding. Endoscopic polidocanol foam sclerobanding (EFSB) is a novel approach that could lift the mucosa for easy ligation and promote increased scarring in the submucosal tissue which translates into long-term relief from prolapse recurrence and reduced 24-h post-procedural pain. The study by Qu et al is a novel multi-center prospective randomized study to compare ERBL and EFSB in patients with grades II and III internal hemorrhoids with one-year follow-up. Results showed that EFSB is a novel therapy for internal hemorrhoids, but future studies with a larger sample, multiple treatment sessions, and long-term follow-up are required to confirm these findings.

Aim: Real-world evidence on the management of hemorrhoidal disease (HD) is limited. This international study collected clinical practice data on the effectiveness of conservative treatments for acute HD on symptoms and quality of life (QoL), providing perspectives of treatment modalities from different continents. Patients & methods: The 4-week observational prospective CHORALIS study involved adult outpatients consulting for spontaneous complaints of hemorrhoids (graded using Goligher classification) and prescribed conservative treatments according to usual clinical practice. Assessments were: anal pain/discomfort (visual analog scale [VAS]), other signs/symptoms (patient questionnaire), Patient Global Impression of Change (PGI-C) questionnaire and disease-specific QoL (HEMO-FISS-QoL questionnaire). Results: Of 3592 participants, 3505 were analyzed (58.4% male; age 40.5 ± 13.7 years; history of HD in 48.4%; 72.1% Goligher grade I and II). Pain and discomfort were the most common symptoms. Most treatments were venoactive drugs (VADs; 90.9%), particularly micronized purified flavonoid fraction (MPFF; 73.7%) and diosmin (14.6%). All VAD-based therapies improved signs/symptoms (number/intensity/frequency of pain, discomfort, bleeding, swelling, itching and soiling) and QoL. MPFF was associated with a significantly greater proportion of patients with no symptoms (48.8 vs diosmin 34.4%, p < 0.001), pain disappearance (69.7 vs diosmin 52.8%, p < 0.001), treatment impact at 1 week rated on PGI-C as 'very much better' (30.5 vs diosmin 17.9%, p < 0.001) and shorter times to improvement (mean ± SD 3.9 ± 1.5 days vs diosmin 4.2 ± 1.7 days). Conclusion: In this prospective real-world study of patients with acute HD, conservative therapies consisting mainly of VADs, including MPFF, improved the clinical signs and symptoms of disease, as well as QoL. This study evidence supports clinical advantages associated with VADs, mostly MPFF, for effectively managing acute HD.

There is no universally accepted treatment consensus for haemorrhoids, and thus, management has been individualized all over the world. This study was conducted to assess a global view of how surgeons manage haemorrhoids.

The research panel of the International Society of University Colon and Rectal Surgeons (ISUCRS) developed a voluntary, anonymous questionnaire evaluating surgeons' experience, volume and treatment approaches to haemorrhoids. The 44 multiple-choice questionnaire was available for one month via the ISUCRS email database and the social media platforms Viber and WhatsApp.

The survey was completed by 1005 surgeons from 103 countries; 931 (92.6%) were in active practice, 819 (81.5%) were between 30 and 60 years of age, and 822 (81.8%) were male. Detailed patient history (92.9%), perineal inspection (91.2%), and digital rectal examination (91.1%) were the most common assessment methods. For internal haemorrhoids, 924 (91.9%) of participants graded them I-IV, with the degree of haemorrhoids being the most important factor considered to determine the treatment approach (76.3%). The most common nonprocedural/conservative treatment consisted of increased daily fibre intake (86.9%), increased water intake (82.7%), and normalization of bowel habits/toilet training (74.4%). Conservative treatment was the first-line treatment for symptomatic first (92.5%), second (72.4%) and third (47.3%) degree haemorrhoids; however, surgery was the first-line treatment for symptomatic fourth degree haemorrhoids (77.6%). Rubber band ligation was the second-line treatment in first (50.7%) and second (47.2%) degree haemorrhoids, whereas surgery was the second-line treatment in third (82.9%) and fourth (16.7%) degree symptomatic haemorrhoids. Rubber band ligation was performed in the office by 645(64.2%) of the participants. The most common surgical procedure performed for haemorrhoids was an excisional haemorrhoidectomy for both internal (87.1%) and external (89.7%) haemorrhoids - with 716 (71.2%) of participants removing 1, 2 or 3 sectors as necessary.

Although there is no global haemorrhoidal treatment consensus, there are many practice similarities among the different cultures, resources, volume and experience of surgeons around the world. With additional studies, a consensus statement could potentially be developed.

Hemorrhoidal disease (HD) significantly impacts patients' quality of life. This study aimed to evaluate the effectiveness of preoperative treatment with the micronized purified flavonoid fraction (MPFF) and a sucralfate-based rectal ointment in managing HD symptoms and reducing interventions.

A prospective quasi-experimental study including consecutive cases and controls matched on the basis of sex was performed in a tertiary referral center. Cases received systemic and local therapy for HD, consisting of a rectal ointment containing 3% sucralfate and herbal extracts plus MPFF, in addition to conservative therapy, while controls received conservative therapy alone. The hemorrhoidal disease symptom score (HDSS), the Short Health Scale for HD (SHS-HD) score, and the Vaizey Incontinence Score were used to evaluate symptoms severity and their impact on quality of life and continence. Intervention requirements were assessed at baseline (T0) and after 60 days of treatment (T1).

Between January and December 2023, a total of 98 patients were assessed for eligibility. After exclusions, 56 patients were enrolled, with 28 in each group. Significant improvements were observed in HD symptom scores from T0 to T1: the intervention group showed a mean change in HDSS of -9 [95% confidence interval (CI) -10 to -8], and the control group showed no significant change (mean change of 0; 95% CI -1.5 to 0). At T1, a higher proportion of patients in the intervention group underwent less invasive interventions compared with controls (18% versus 11%). Age, treatment group, and baseline symptom severity significantly predicted post-treatment symptom scores.

In our study the preoperative treatment with MPFF and a sucralfate-based rectal ointment demonstrated clinical benefits in managing HD symptoms and reducing interventions. Further prospective trials are warranted to confirm and explore additional therapeutic strategies.

Observational studies have reported an association between inflammatory bowel disease (IBD), which includes Crohn's disease (CD) and ulcerative colitis (UC), and hemorrhoids (HEM). However, the presence of a causal relationship within this observed association remains to be confirmed. Consequently, we utilized the Mendelian randomization (MR) method to assess the causal effects of IBD on hemorrhoids. We validated the association between IBD and hemorrhoids in humans based on genome-wide association studies (GWAS) data. To investigate the causal relationship between IBD and hemorrhoids, we performed a two-sample Mendelian randomization study using training and validation sets. The genetic variation data for IBD, CD, UC, and hemorrhoids were derived from published genome-wide association studies (GWAS) of individuals of European. Two-sample Mendelian randomization and Multivariable Mendelian randomization (MVMR) were employed to determine the causal relationship between IBD (CD or UC) and hemorrhoids. Genetically predicted overall IBD was positively associated with hemorrhoids risk, with ORs of 1.02 (95% CIs 1.01-1.03, P = 4.39 × 10-4) and 1.02 (95% CIs 1.01-1.03, P = 4.99 × 10-5) in the training and validation sets, respectively. Furthermore, we found that CD was positively associated with hemorrhoids risk, with ORs of 1.02 (95% CIs 1.01-1.03, P = 4.12 × 10-6) and 1.02 (95% CIs 1.01-1.02, P = 3.78 × 10-5) for CD in the training and validation sets, respectively. In addition, we found that UC in the training set was positively associated with hemorrhoids risk (ORs 1.02, 95% CIs 1.01-1.03, P = 4.65 × 10-3), while no significant causal relationship between UC and hemorrhoids was shown in the validation set (P > 0.05). However, after MVMR adjustment, UC in the training set was not associated with an increased risk of hemorrhoids. Our study showed that there is a causal relationship between CD and hemorrhoids, which may suggest that clinicians need to prevent the occurrence of hemorrhoids in CD patients.

Background: The aim of this study was to assess whether the frequency and presentation modality of hemorrhoidal prolapse may have an impact on patients' quality of life, leading to a different categorization of patients. Methods: A consecutive series of patients affected by primary hemorrhoidal disease were administered specific questionnaires to assess the severity of symptoms and their quality of life. The frequency/modality of prolapse was also assessed, and the classification of the patients into five categories was hypothesized. The severity of disease was assessed using a validated patient-reported score, while the health-related quality of life was evaluated with the Short Health Scale for hemorrhoidal disease. Results: A total of 122 patients were enrolled. The evaluation of the prolapse modality led to the following classification: type I, 5 patients (4.1%); type II, 9 (7.4%), type IIIa, 48 (39.3%); type IIIb, 52 (42.6%); and type IV, 8 (6.6%). The mean total hemorrhoidal disease score was 9.8 ± 3.3, while the mean total Short Health Scale score was 18.6 ± 5.2. Both scores progressively increased in the five types of prolapse identified, thus showing a worsening of symptoms and quality of life related to the increase in the frequency and modality of prolapse. The assessment of the quality of life showed that all four domains of the Short Health Scale score and the total score were significantly worse in group IIIb compared to IIIa. Conclusions: The frequency and modality of hemorrhoidal prolapse has an impact on the quality of life and allows the identification of new types of patients.

Hemorrhoid disease is a common anorectal disorder affecting populations worldwide, with high prevalence, treatment difficulties, and considerable treatment costs. Compared to other treatment options, medical therapy for hemorrhoids offers minimal harm, more dignity to patients, and is more economical. Unfortunately, there are few chemical hemorrhoid medications available clinically, which makes the search for efficacious, cost-effective, and environmentally friendly new medication classes a focal point of research. In this context, searching for available natural products to improve hemorrhoids exhibits tremendous potential. These products are derived from nature, predominantly from plants, with a minor portion coming from animals, fungi, and algae. They have excellent coagulation pathway regulation, anti-inflammatory, antibacterial, and tissue regeneration activities. Therefore, we take the view that they are a class of potential hemorrhoid drugs, prevention products, and medication add-on ingredients. This article first reviews the factors contributing to the development of hemorrhoids, types, primary symptoms, and the mechanisms of natural products for hemorrhoids. Building on this foundation, we screened natural products with potential hemorrhoid improvement activity, including polyphenols and flavonoids, terpenes, polysaccharides, and other types.

There are very few French studies on hemorrhoidal disease and its management.

Prospective single-center study from July to December 2021 including 472 patients.

Bleeding, prolapse and pain were the main reasons for consultation. Treatment modalities were medical (44%),±instrumental (72%), and surgical (17%). After treatment, the bleeding score and prolapse score decreased significantly (P=0.002 and P≤0.0001, respectively), but improvement was more marked in the surgery group with a better rate of "very good satisfaction" (73% vs. 54%, P=0.003). Factors associated with likelihood of surgical treatment were: age>44years, hypertrophic perianal skin tags, high scores (Bristol>5, bleeding>5, prolapse>2), severe impact on quality of life, smoking and reading during bowel movements. We have developed an online application, which aims to assess the risk of requiring hemorrhoidal surgery.

Less than 20% of patients who present with hemorrhoidal disease require surgical treatment, but it is associated with better effectiveness despite more complex postoperative consequences that sometimes motivate patient refusal. We have highlighted factors associated with surgical management, which can guide the practitioner in their therapeutic choices.

Haemorrhoidal disease (HD) is one of the most common anal disorders in the adult population. Despite that, treatment options differ among different countries and specialists, even for the same grade of HD. The aim of this study is to evaluate the differences in patient demographics, surgeon preference for the treatment option, outcomes as well as patient satisfaction rate for the procedure using an office-based or surgical approach for the treatment of HD among International Society of University Colon and Rectal Surgeons (ISUCRS) and European Society of Coloproctology (ECSP) fellows.

A panel of the ISUCRS and ECSP members will answer questions that are included in a questionnaire about the treatment of HD. The questionnaire will be distributed electronically to ISUCRS and ECSP fellows included in our database and will remain open from 1 April 2024 to 31 May 2024.

This multicentre, global prospective audit will be delivered by consultant colorectal and general surgeons as well as trainees. The data obtained will lead to a better understanding of the incidence of HD, treatment and diagnostic possibilities. This snapshot audit will be hypothesis generating and inform areas the need future prospective study.

Internal hemorrhoids (IH) is a common medical condition that can result in morbidity secondary to bleeding and discomfort. Treatment for IH has traditionally consisted of dietary and conservative medical management, focal treatments including banding and sclerotherapy or hemorrhoidectomy. Recently, rectal artery embolization (RAE) has been studied as a potential treatment for bleeding predominant IH. We performed a common design and data element analysis of studies that report on RAE.

We conducted a qualitative systematic literature review for rectal artery embolization (RAE) for symptomatic hemorrhoidal disease. The screening process involved five online databases (PubMed, Embase, Google Scholar, DOAJ, and Scopus). Additionally, ClinicalTrials.gov was examined for active, unpublished completed studies. The initial search yielded 2000 studies, with 15 studies meeting the inclusion criteria after screening and assessment. The included studies comprised one RCT, one case series, one pilot study and 12 cohort studies.

The population analysis revealed a male predominance across all studies, with varying cohort sizes. The baseline Goligher hemorrhoid grade was utilized in 80% of studies. The majority (73.3%) employed a transfemoral approach, and coils were the primary embolic material in 60% of studies, 26.6% were combination of coils and particles, and 6.6% were particles only. Patient selection criteria highlighted RAE's applicability for high surgical risk patients and those with anemia, chronic hematochezia, or treatment-refractory cases. Exclusion criteria emphasized factors such as previous surgeries, colorectal cancer, rectal prolapse, acute hemorrhoidal complications, and contrast allergy. Study designs varied, with cohort studies being the most common (12/15; 80%). Procedural details included the use of metallic coils and detachable micro-coils, with a high technical success rate reported in most studies ranging from 72 to 100%. The follow-up ranged from 1 to 18 months. The majority of studies reported no major immediate or post-procedural complications.

While all studies focused on RAE as a treatment for IH, there was a great degree of heterogeneity among included studies, particularly regarding inclusion criteria, exclusion criteria, outcomes measures and timeframe. Future literature should attempt to standardize these design elements to help facilitate secondary analyses and increase understanding of RAE as a treatment option.

Unplanned readmission is often seen after excisional hemorrhoidectomy. This study aims to explore associations between patient and operative factors, and readmission rates in excisional hemorrhoidectomy.

We performed a retrospective analysis of all excisional hemorrhoidectomies performed in Capital and Coast District Health Board for an 8-year period from January 1, 2012, to December 31, 2020. The primary outcome measure was 30-day readmissions post hemorrhoidectomy. Univariate and multivariable logistic regression analyses were performed to identify risk factors to readmisson. A decision tree model was designed to further look at the interactions between risk factors.

There were a total 370 patients undergoing 389 excisional hemorrhoidectomies over the study period. There were 47 (12.1%) readmissions. The commonest reasons for readmission were pain (48.9%) and bleeding (38%). 17% of readmitted patients required operative intervention. Readmission was associated with the use of advanced energy devices (OR 2.21; P = 0.027). Trainees were more likely to use advance energy devices than consultants (51% versus 38%, P = 0.010). Consultants were involved in more procedures requiring a removal of 3 pedicles or more than trainees (43% versus 30%, P = 0.010). A decision tree model predicts readmission based on primary operator experience, age, advanced energy device use, and patient ethnicity.

Two risk models are presented showing the complex relationship between the factors associated with readmission after hemorrhoidectomy. Advanced energy device use was associated with an increased risk of readmission after hemorrhoidectomy in our population. Future work could involve targeted interventions to patients at increased risk of readmission such as preprocedural and postprocedural information, early interval follow-up and targeted analgesia regimes.

Internal hemorrhoids are a common issue in general surgery and are one of the leading causes of lower gastrointestinal bleeding globally. Numerous treatment options exist for managing this challenging condition. One relatively new treatment method is radiofrequency ablation for internal hemorrhoids (RAFAELO). According to the limited publications, this method is described as simple, quick, and safe. In this case series, we present five patients with internal hemorrhoids who were treated using the RAFAELO method and discuss their management and outcomes.

The management of thrombosed external hemorrhoids (TEH) during pregnancy is still under debate because of the fear of potential adverse effects on the fetus. This study aims to compare efficacy and safety of conservative versus surgical treatment of acute TEH in pregnant women. Furthermore, the outcome of two different surgical approaches was evaluated. This is a prospective observational study including a sub-analysis on two randomized groups of pregnant women affected by TEH. The primary outcome measured was the impact of conservative and surgical treatment defined in terms of VAS, clinical patient grading assessment scale (CPGAS) and the SF-12 questionnaire. In a randomized sub-analysis of the surgical treatment, the outcome of local excision (LE) versus thrombectomy (TE) was compared. Fifty-three patients entered the study. Twenty-six patients had conservative treatment and 22 underwent surgery. Within the surgical group, 8 were randomized for TE and 14 for LE. VAS, SF-12 and CPGAS improved in both groups after 3 and 10 days from the treatment. However, physical (PCS) and mental health (MCS) domains of the SF-12 and CPGAS showed a significant difference in favor of surgery on the 10th day (PCS: p < 0.002 and MCS: p = 0.03; CPGAS: p = 0.002). The surgical group showed an earlier significant reduction of pain on the 3rd day (p = 0.0004). In the surgical group, randomization was halted due to ethical concerns arising from a notable difference in the primary end point between subgroups during interim analysis. Specifically, the re-thrombosis rate was 38% (3/8) after TE and 7% (1/14) after LE. No complications occurred for either mothers or fetuses. Both surgical and conservative treatments are safe and effective. However, surgery allows a faster relief of anal pain. Thrombectomy is associated with higher risk of re-thrombosis when compared to local excision (clinicaltrials.gov ID number NCT04588467).

The estimated prevalence of hemorrhoidal disease (HD) worldwide ranges from 2.9% to 27.9%. Conservative, medical, non-operative, and surgical therapy approaches are applied in HD treatment. Milligan-Morgan (MM) hemorrhoidectomy which is the most well-known and frequently applied surgical treatment method, and Laser hemorrhoidoplasty (LH) are among the accepted treatment methods in Grade 2-3 HD treatment where medical treatment is insufficient.

In this study, the early results of laser hemorrhoidoplasty and Milligan-Morgan hemorrhoidectomy techniques were compared.

A randomized clinical trial. The study included ASA 1-3, total 85 patients aged 18-70 years old with symptomatic Grade 2 and Grade 3 hemorrhoidal disease whose symptoms persisted despite at least one month of medical treatment. Fifty-four patients were allocated to Group L, whereas 31 were allocated to Group M. Age, gender, weight, body mass index, preoperative symptoms, presence of additional disease, use of anticoagulant medication, and length of hospital stay of the patients included in the study were recorded. Rescue analgesic used was recorded. Postoperative VAS score and complications were recorded within 10 days. The total energy numbers applied to all packages were recorded.

The incidence of minor perioperative hemorrhage was significantly lower in Group L compared to Group M (P = .035). The postoperative 3rd-hour VAS scores were statistically significantly lower in Group L compared to Group (P < .001). At the 3rd hour postoperatively, the need for rescue analgesia was statistically significantly higher in Group M compared to Group L. On the seventh postoperative day, Group M needed considerably more rescue analgesia compared to Group L (P < .001, P = 1.00, P = .035, respectively). The cut-off value of 571 J was calculated in Group L.

We believe that it is not an advantageous method compared to MM hemorrhoidectomy, both in terms of patient comfort and cost-effectiveness, since postoperative pain, which is shown as the most important advantage of LH over conventional hemorrhoidectomy methods in the literature, can be relieved with simple NSA-I rescue analgesia in patients undergoing MM. Trial Registration: 03.06.2021/21-63.

Doctors are at high risk of developing hemorrhoidal disease (HD), but it is unclear whether doctors are aware of this risk. The OASIS (dOctors AS patIentS) study was performed to examine the prevalence, awareness, diagnosis, and treatment of HD among doctors in big cities in China.

An online survey consisting of a structured questionnaire was carried out among doctors in grade-A tertiary hospitals in 29 provinces across China from August to October 2020.

A total of 1227 questionnaire responses were collected. HD prevalence was 56.8%, with a significant difference between internists and surgeons (P = 0.01). 15.6% of doctors with HD didn't have serious concerns about the recurrence and severity of HD. 91.5% of doctors adopted general treatments, and 83.0% considered oral medications only when topical medications were ineffective. Among the oral medications, Micronized Purified Flavonoid Fraction (MPFF) was most effective based on the scores from three important parameters, but only 17% of doctors received MPFF.

Doctors are at higher risk of developing HD with a high prevalence among Chinese doctors, but they are not fully aware or not concerned about HD. There is a deficiency in treatment recommendations and clinical management of HD even for doctors, including late initiation and inadequate oral drug therapy. Therefore, awareness and standardized treatment of HD should be improved among Chinese doctors, as well as in the general population.

While haemorrhoidal dearterialization and mucopexy are accepted as a valid alternative to haemorrhoidectomy, differences exist regarding the fixed or variable location of the arteries to be ligated. Our aim was to shed light on this issue of arterial distribution in candidates for surgery.

The study included consecutive patients diagnosed with Goligher grade III and IV haemorrhoids, who had undergone Doppler-guided haemorrhoidal artery ligation (DG-HAL) and rectoanal repair (RAR) at 2 medical centres in Spain. The main objective was to evaluate the number and 12-h clock locations of arterial ligatures necessary to achieve Doppler silence.

In total, 146 patients were included: 111 (76%) men, and 35 (24%) women. Average age was 54 years (21-84). Grade III and grade IV haemorrhoids were diagnosed in 106 (72.6%) and 40 (27.4%) patients, respectively. The average number of ligatures per patient was 7 (range 2-12). Ligature percentages greater than 60% occurred at clock positions 7, 11, 10, 12, 9, and 1. The average number of mucopexies per patient was 3 (range 1-4). The most frequent mucopexy locations were the left posterior, right posterior, and right anterior octants.

While the greatest frequency of arterial ligatures occurred in odd-numbered clock positions, non-negligible percentages occurred in even-numbered clock positions, which, in our opinion, makes the use of Doppler necessary, given that arterial distribution is not the same in all patients. We also noted that more ligatures and mucopexies were needed on the right half of the rectal circumference than on the left side, suggesting greater right-side vascularization.

Introduction Haemorrhoids and anal fissures (HAF) are common in pregnancy and can severely affect the quality of life of those suffering from them. Despite the condition being common, there is limited evidence, formal guidelines or recommendations on treatment, and little is known about the natural course during pregnancy. Methods This was a prospective, observational cohort study conducted at a tertiary-referral university maternity hospital (The National Maternity Hospital, Dublin), conducted over a nine-month period. The first part of the study was a case-control study of antenatal patients over 34 weeks' gestation. The second part of the study involved a cohort of postnatal patients. Anonymous patient surveys were performed and analysed. Results Two hundred and fifty-eight patients were recruited into the study from the outpatient clinics and wards of one maternity hospital from April to December 2021. Of the antenatal patients, 82/184 (45%) of these patients had symptoms of HAF and 102/184 (55%) antenatal patients were unaffected, acting as controls. In addition, 74 affected postnatal patients were also included. In the affected antenatal group, 36/82 (44%) of patients had self-reported HAF (symptoms or signs of HAF); 50/82 (61%) of patients diagnosed with HAF on their own. 12/82 (15%) noticed symptoms in the first trimester, 25/82 (30%) in the second and 45/82 (55%) in the third. 142/184 (77%) of antenatal patients used conservative methods to manage their symptoms, including an increase in dietary fibre. 144/184 (78%) used medical treatments including suppositories. Only one patient had surgery. 70/156 (45%) of postnatal patients' symptoms resolved within days, 42/156 (27%) in weeks and 44/156 (28%) within months. Conclusion HAF affect almost half of the pregnancies. Age over 35 was significantly associated with antenatal haemorrhoids or anal fissures. Concerningly, the majority of patients (64%) self-diagnose and manage the condition without either seeking or receiving guidance from medical professionals. In terms of the natural course of the disease, it was encouraging that 45% of patients' symptoms resolved within a few days. This will help when counselling patients with distressing symptoms. Conservative measures such as increased dietary fibre, increased fluid intake and bath salts were effective in relieving symptoms for the majority of patients.

This systematic review and meta-analysis aimed to evaluate the safety and efficacy of sclerotherapy methods for hemorrhoidal disease (HD) over the past 40 years.

The review followed the 2020 Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A comprehensive literature search was conducted, including studies reporting the use of sclerotherapy in patients with HD. Study eligibility criteria were defined, and data were extracted independently by the authors. Random-effects meta-analyses were performed to assess outcomes of interest.

Out of 1965 records identified, 44 studies met the inclusion criteria, involving 9729 patients. The majority of studies were conducted in Japan, followed by the UK, Italy, and Portugal. The median age of participants was 52 years, and the majority were male. The Goligher grade distribution indicated varying degrees of HD severity. Sclerotherapy was predominantly administered through anoscopy, with polidocanol being the most commonly used agent. The procedure was generally performed without pre-injection analgesia. The meta-analysis of 14 randomized controlled trials (RCTs) revealed that sclerotherapy was not inferior to control interventions in terms of success rate (risk ratio [RR] 1.00, 95% CI 0.71-1.41) and recurrence rate (RR 1.11, 95% CI 0.69-1.77), while resulting in fewer complications (RR 0.46, 95% CI 0.23-0.92).

This systematic review highlights the safety and efficacy of sclerotherapy for HD, which yields similar success rates and fewer complications compared to other conservative or surgical approaches. Further research is warranted to optimize sclerotherapy techniques and evaluate long-term outcomes.

PROSPERO 2023 CRD42023396910.

The primary aim of the European Society of Coloproctology (ESCP) Guideline Development Group (GDG) was to produce high-quality, evidence-based guidelines for the management of cryptoglandular anal fistula with input from a multidisciplinary group and using transparent, reproducible methodology.

Previously published methodology in guideline development by the ESCP has been replicated in this project. The guideline development process followed the requirements of the AGREE-S tool kit. Six phases can be identified in the methodology. Phase one sets the scope of the guideline, which addresses the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula in adult patients presenting to secondary care. The target population for this guideline are healthcare practitioners in secondary care and patients interested in understanding the clinical evidence available for various surgical interventions for anal fistula. Phase two involved formulation of the GDG. The GDG consisted of 21 coloproctologists, three research fellows, a radiologist and a methodologist. Stakeholders were chosen for their clinical and academic involvement in the management of anal fistula as well as being representative of the geographical variation among the ESCP membership. Five patients were recruited from patient groups to review the draft guideline. These patients attended two virtual meetings to discuss the evidence and suggest amendments. In phase three, patient/population, intervention, comparison and outcomes questions were formulated by the GDG. The GDG ratified 250 questions and chose 45 for inclusion in the guideline. In phase four, critical and important outcomes were confirmed for inclusion. Important outcomes were pain and wound healing. Critical outcomes were fistula healing, fistula recurrence and incontinence. These outcomes formed part of the inclusion criteria for the literature search. In phase five, a literature search was performed of MEDLINE (Ovid), PubMed, Embase (Ovid) and the Cochrane Database of Systematic Reviews by eight teams of the GDG. Data were extracted and submitted for review by the GDG in a draft guideline. The most recent systematic reviews were prioritized for inclusion. Studies published since the most recent systematic review were included in our analysis by conducting a new meta-analysis using Review manager. In phase six, recommendations were formulated, using grading of recommendations, assessment, development, and evaluations, in three virtual meetings of the GDG.

In seven sections covering the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula, there are 42 recommendations.

This is an up-to-date international guideline on the management of cryptoglandular anal fistula using methodology prescribed by the AGREE enterprise.

Milligan-Morgan hemorrhoidectomy (MMH) is the most widely used surgical procedure because of its precise curative effect, but it has the disadvantages such as obvious postoperative pain and bleeding. To retrospectively evaluate the efficacy and safety of MMH combined with non-Doppler hemorrhoidal artery ligation (MMH + ND-HAL) for the treatment of grade III/IV hemorrhoids.

We conducted a retrospective analysis of 115 patients with grade III/IV hemorrhoids, 53 patients had received MMH + ND-HAL, and the remaining 62 patients received MMH. We collected and compared demographic and clinical characteristics of both groups, including intraoperative blood loss, postoperative visual analog scale (VAS) for pain, analgesic consumption, postoperative bleeding, perianal incision edema, urinary retention, anal stenosis, anal incontinence incidence, recurrence rate (prolapse or bleeding), and patient satisfaction.

The VAS pain score of the first postoperative defecation and at the postoperative 12 h, 1 day, 2 days, 3 days, and 7 days, as well as the total analgesic consumption within 7 days, for the MMH + ND-HAL group were lower than those for the MMH group (P < 0.05). The intraoperative blood loss, the incidence of postoperative bleeding, perianal incision edema, and urinary retention in the MMH + ND-HAL group was lower than that in the MMH group (P < 0.05). No anal stenosis or anal incontinence occurred in either group. At follow-up by telephone or outpatient 12 months after surgery, the recurrence rate (prolapse or bleeding) was lower in the MMH + ND-HAL group than in the MMH group (P < 0.05), and satisfaction was higher in the MMH + ND-HAL group than in the MMH group (P < 0.05).

MMH + ND-HAL was a satisfactory surgical modality for treating III/IV hemorrhoids.

Available guidelines describing the procedural treatment of thrombosed external hemorrhoids (TEH) rely solely on expert opinion. We aimed to compare local excision (LE) and thrombectomy (incision) in terms of treatment success, factors affecting success, and outcomes.

This was a multicenter, prospective, observational study conducted in eight centers from September 2020 to September 2021. A total of 96 patients (58 LE, 38 thrombectomy) were included. Risk factors, demographics and clinical characteristics were recorded. Follow-up studies were scheduled for the 1st week, 1st, 3rd and 6th months. Surgical success was assessed at 1 month. Hemorrhoidal Disease Symptom Score (HDSS) and Short Health Scale (SHS) were applied at baseline and the 6th month. Wexner fecal incontinence score was applied at all follow-up studies.

Overall mean age was 41.5 ± 12.7 years. At baseline, groups were similar with regard to demographics and disease severity (HDSS) (p > 0.05 for all). Success was relatively higher in the thrombectomy group (86.8%) compared to the LE group (67.2%) (p = 0.054). Constipation and travel history were significantly associated with lower likelihood of LE success. Symptoms during follow-up were similarly distributed in the groups. Both methods yielded significant improvements in HDSS, SHS and Wexner scores; however, SHS scores (6 months) and Wexner scores (all time points) were significantly better in the thrombectomy group.

The in-office thrombectomy procedure may have better short-term outcomes compared to LE in terms of relative success, recurrence and quality of life-despite the fact that success rates were statistically similar with the two interventions. LE may yield particularly worse results in patients with constipation and travel history; thus, thrombectomy appears to be especially advantageous in these patient subsets.

The main objective of this study was to assess the impact on quality of life after rubber band ligation (RBL) in patients with symptomatic grade II-III haemorrhoids who did not improve after 6 months of conservative treatment, using quality of life scores.

This was a prospective cohort observational study where patients with haemorrhoidal disease and indication for RBL were included between December 2019 and December 2020. RBL was offered as first-line treatment in this group. Patient´s quality of life was assessed by scores: HDSS (Hemorrhoidal Disease Symptom Score) and SHS (Short Health Scale).Secondary objectives were: to evaluate the rate of patients requiring one or more RBL procedures, to establish the overall success rate of RBL and to analyse complications.

A total of 100 patients were finally included. Regarding the impact on quality of life after RBL, a significant reduction was found in the HDSS and SHS scores (p < 0.001). The main improvement was found in the first month and it was maintained until the sixth month. A high degree of satisfaction with the procedure was reported by 76% of patients. The overall success rate of banding was 89%. A 12% complication rate was detected, the most frequent complication was severe anal pain (58.3%) and self-limiting bleeding (41.7%).

Rubber band ligation, as a treatment for symptomatic grade II-III haemorrhoids that do not respond to medical treatment, leads to a significant improvement in patients' symptoms and quality of life. It also has a high degree of satisfaction between patients.

Haemorrhoidal disease (HD) affects a considerable portion of the adult population. The aim of this study is to confirm the safety and efficacy of the treatments and to report the long-term outcomes of Sclerotherapy (ST) and Mucopexy and Haemorrhoidal Dearterialization (MHD) performed over the last 4 years in a single tertiary centre. The secondary outcome is to evaluate the usefulness of both techniques and to demonstrate how those can be associated as a bridge to surgery.

Patients affected by second-third-degree haemorrhoids and undergoing ST or non-Doppler guided MHD between 2018 and 2021 were enrolled. Safety and efficacy, recurrence rate, Haemorrhoid Severity Score (HSS) and pain resulting from both techniques were evaluated.

Out of 259 patients, 150 underwent ST. Further, 122 (81.3%) patients were male and 28 (18.7%) were female. The mean age was 50.8 (range 34-68) years. Most of the patients (103, 68.6%) were affected by second-degree HD, while 47 (31.4%) were affected by third-degree HD. The overall success rate was 83.3%. The median pre-operative HSS score was 3 (IQR 0-4, p = 0.04) and at 2 year the median HSS was 0 (IQR 0-1, p = 0.03). No intraoperative complications and no drug-related side effects occurred. The mean follow-up for ST was 2 years (range 1-4; SD ±0.88). MHD was performed on 109 patients. In detail, 80 patients (73.4%) were male while 29 patients (26.6%) were female. The mean age in this group was 51.3 (range 31-69). Further, 72 patients (66.1%) were affected by third-degree HD and 37 (33.9%) by second-degree HD. The median HSS score was 9 (IQR 8-10, p = 0.001) preoperatively two years after treatment was 0 (IQR 0-1, p = 0.004). Major complications occurred in three patients (2.75%). The overall success rate was 93.5% (second degree 89.2% vs. third degree 95.8%). The mean follow-up for MHD was 2 years (range 1-4; SD ±0.68).

The results confirm the usefulness of those techniques, which can be considered safe and easily repeatable procedures, with a low recurrence rate after 2 years of median follow-up.

Up to 20% of patients suffering from symptomatic hemorrhoids will require surgery. Excisional hemorrhoidectomy (EH) and stapled hemorrhoidopexy (SH) are both standard and safe procedures. While SH has a short-term advantage of faster recovery and lower postoperative pain, its long-term efficacy is debatable. This study aims to compare the outcomes of EH, SH, and a combined procedure of both.

A retrospective study compared the outcomes of patients treated surgically for hemorrhoids over a 5-year period. Eligible patients were asked by phone to complete a questionnaire evaluating recurrent symptoms, fecal incontinence, satisfaction, and self-assessed improvement in quality of life (QOL).

This study included 362 patients, of whom 215 underwent SH, 99 underwent EH, and 48 underwent a combined procedure. No statistically significant differences were found between groups regarding complications, symptoms recurrence, or fecal incontinence. Combined procedure patients had significantly higher self-assessed improvement in QOL (P=0.04).

In patients with symptomatic hemorrhoids, a tailored approach to symptomatic hemorrhoids is associated with high satisfaction rates and self-assessed improvement in QOL.

Haemorrhoidal disease (HD) is a common condition with significant epidemiologic and economic implications. While it is possible to treat symptomatic grade 1-2 haemorrhoids with rubber band ligation (RBL) or sclerotherapy (SCL), the effectiveness of these treatments compatible with current standards has not yet been investigated with a randomised controlled trial. The hypothesis is that SCL is not inferior to RBL in terms of symptom reduction (patient-related outcome measures (PROMs)), patient experience, complications or recurrence rate.

This protocol describes the methodology of a non-inferiority, multicentre, randomised controlled trial comparing rubber band ligation and sclerotherapy for symptomatic grade 1-2 haemorrhoids in adults (> 18 years). Patients are preferably randomised between the two treatment arms. However, patients with a strong preference for one of the treatments and refuse randomisation are eligible for the registration arm. Patients either receive 4 cc Aethoxysklerol 3% SCL or 3 × RBL. The primary outcome measures are symptom reduction by means of PROMs, recurrence and complication rates. Secondary outcome measures are patient experience, number of treatments and days of sick leave from work. Data are collected at 4 different time points.

The THROS trial is the first large multicentre randomised trial to study the difference in effectivity between RBL and SCL for the treatment of grade 1-2 HD. It will provide information as to which treatment method (RBL or SCL) is the most effective, gives fewer complications and is experienced by the patient as the best option.

The study protocol has been approved by the Medical Ethics Review Committee of the Amsterdam University Medical Centers, location AMC (nr. 2020_053). The gathered data and results will be submitted for publication in peer-reviewed journals and spread to coloproctological associations and guidelines.

Dutch Trial Register NL8377 . Registered on 12-02-2020.

Hemorrhoidal artery ligation (HAL) may reduce postoperative pain and complications and shorten patients' recovery when compared to standard hemorrhoidectomy. It is unclear if the Doppler guide (DG) is useful in reducing recurrence risk.

To compare two groups of patients (treated with DG-HAL or HAL) in terms of recurrence risk and patients' satisfaction grade.

Between January 1, 2014 and January 31, 2021, 122 patients affected by grade II-III hemorrhoidal prolapse underwent DG-HAL or HAL at Chivasso Hospital, Italy. Mucopexy was routinely performed. After discharge, patients were subjected to 1-week, 1-, 3-, 6-, and 12-month clinical assessment. Thereafter, they were interviewed by telephone annually.

Seventy-six (62.3%) DG-HAL and 46 (37.7%) HAL procedures were performed. Median surgical time was 30 (15-45) minutes for DG-HAL versus 25 (15-40) minutes for HAL (P = 0.005). No intraoperative complications occurred. Postoperative bleeding needing surgery occurred in 2 (1.6%) patients in the DG-HAL group. During a median follow-up of 46 months (6-86), we registered 18 (23.7%) recurrences in the DG-HAL group and 13 (28.3%) in the HAL one (P = 0.574). No cases of incontinence or anal stenosis occurred. No significant difference was observed between the two groups in terms of patients' satisfaction. At multivariate analysis, age ≥ 65 years resulted a protective factor for recurrence (odds ratio 0.31; 95% confidence interval 0.09-0.98; P = 0.047).

In our study, the use of DG did not reduce recurrence risk. Operative time was significantly increased in the DG-HAL group.

Endoscopic rubber band ligation (ERBL) is considered an effective nonsurgical treatment for symptomatic grade I to III hemorrhoids; however, it is unclear whether ligation of hemorrhoids or simultaneous ligation of hemorrhoids and proximal normal mucosa (combined ligation) is safer and more effective. This controlled, open-label, and prospective study aimed to evaluate the efficacy and safety of both methods for symptomatic grade I to III hemorrhoids.

Seventy patients with symptomatic grade I to III hemorrhoids were randomly assigned to the hemorrhoid and combined ligation groups (35 in each group). Patients were followed up at 3, 6, and 12 months to assess symptom improvement, complications, and recurrence. The primary outcome was overall therapeutic success rate (complete resolution and partial resolution rates). The secondary outcomes included recurrence rate and efficacy for each symptom. Complications and patient satisfaction were also assessed.

Sixty-two patients (31 in each group) completed the 12-month follow-up; 42 (67.8%) experienced complete resolution, 17 (27.4%) experienced partial resolution, and 3 (4.8%) experienced no change in overall efficacy. The rates of complete resolution, partial resolution, and no change in the hemorrhoid ligation and combined ligation groups were 71.0 and 64.5%, 22.6 and 32.3%, and 6.5 and 3.2%, respectively. No significant differences in overall efficacy, recurrence rate, or efficacy for each symptom (including bleeding, prolapse, pain, anal swelling, itching, soiling, and constipation) were observed between groups. No life-threatening events requiring surgical intervention occurred. The incidence of postoperative pain was higher in the combined ligation group (74.2% vs. 45.2%, P = 0.02). No significant differences between groups in terms of incidences of other complications or patient satisfaction were observed.

Both methods achieved satisfactory therapeutic effects. No significant differences in efficacy and safety of the two ligation methods were observed; however, combined ligation resulted in a higher incidence of postprocedural pain.

Laser Hemorrhoidoplasty (LHP) is a novel therapeutic option for hemorrhoids. In this study, we aimed to evaluate the post-operative outcomes of patients undergoing LHP surgery based on hemorrhoid grade. A retrospective analysis of a prospective database of all patients who underwent LHP surgery between September 2018 and October 2021 was performed. Patients' demographics, clinical perioperative data, and post-operative outcomes were recorded and analyzed. One hundred and sixty two patients that underwent laser hemorrhoidoplasty (LHP) were included. Median operative time was 18 min (range 8-38). Median total energy applied was 850 Joule (450-1242). Complete remission of symptoms following surgery was reported by 134 patients (82.7%), while 21 patients (13%) reported partial symptomatic relief. Nineteen patients (11.7%) presented with post-operative complications, and 11 patients (6.75%) were re-admitted following surgery. Post-operative complication rate was significantly higher in patients with grade 4 hemorrhoids compared to grades 3 or 2, due to a higher rate of post-operative bleeding (31.6% vs. 6.5% and 6.7%, respectively; p = 0.004). Furthermore, post-operative readmission rate (26.3% vs. 5.4% and 6.2%; p = 0.01) and reoperation rate were also significantly higher in grade IV hemorrhoids (21.1% vs. 2.2% and 0%; p = 0.001). Multivariate analysis found that grade IV hemorrhoids had a significantly higher risk for post-operative bleeding (OR 6.98, 95% CI 1.68-28.7; p = 0.006), 30-day readmission (OR 5.82, 95% CI 1.27-25.1; p = 0.018), and hemorrhoids recurrence (OR 11.4, 95% CI 1.18-116; p = 0.028). LHP is an effective treatment for hemorrhoids grades II-IV, but carries significant risk for bleeding and re-intervention in patients with grade IV hemorrhoids.