Published online Nov 26, 2019. doi: 10.12998/wjcc.v7.i22.3742
Peer-review started: August 14, 2019
First decision: October 14, 2019
Revised: October 21, 2019
Accepted: October 30, 2019
Article in press: October 30, 2019
Published online: November 26, 2019
Hemorrhoidal disease is the most common anorectal disorder. Hemorrhoids can be classified as external or internal, according to their relation to the dentate line. External hemorrhoids originate below the dentate line and are managed conservatively unless the patient cannot keep the perianal region clean, or they cause significant discomfort. Internal hemorrhoids originate above the dentate line and can be managed according to the graded degree of prolapse, as described by Goligher. Generally, low-grade internal hemorrhoids are effectively treated conservatively, by non-operative measures, while high-grade internal hemorrhoids warrant procedural intervention.
To determine the application of clinical practice guidelines for the current management of hemorrhoids and colorectal surgeon consensus in Australia and New Zealand.
An online survey was distributed to 206 colorectal surgeons in Australia and New Zealand using 17 guideline-based hypothetical clinical scenarios.
There were 82 respondents (40%) to 17 guideline-based scenarios. Nine (53%) reached consensus, of which only 1 (6%) disagreed with the guidelines. This was based on low quality evidence for the management of acutely thrombosed external hemorrhoids. There were 8 scenarios which showed community equipoise (47%) and they were equally divided for agreeing or disagreeing with the guidelines. These topics were based on low and moderate levels of evidence. They included the initial management of grade I internal hemorrhoids, grade III internal hemorrhoids when initial management had failed and the patient had recognised risks factors for septic complications; and finally, the decision-making when considering patient preferences, including a prompt return to work, or minimal post-operative pain.
Although there are areas of consensus in the management of hemorrhoids, there are many areas of community equipoise which would benefit from further research.
Core tip: Clinical practice guidelines are created to recommend therapies based on the highest levels of evidence. It becomes important to determine whether clinical practice is reflecting management outlined in these guidelines. This paper is the first to assess Australian and New Zealand practice with guidelines in the management of hemorrhoids. While this study has identified areas of colorectal surgeon consensus with hemorrhoid clinical practice guidelines, many more areas of community equipoise have been found, including the initial management of internal hemorrhoids. It is these areas of uncertainty and disagreement which would benefit from high quality research.