Published online Jan 16, 2023. doi: 10.12998/wjcc.v11.i2.366
Peer-review started: November 26, 2022
First decision: December 13, 2022
Revised: December 16, 2022
Accepted: January 3, 2023
Article in press: January 3, 2023
Published online: January 16, 2023
Processing time: 46 Days and 14.5 Hours
For many years hemorrhoidal disease (HD) has been perceived by society as a low-severity pathology, this perception being adopted even by physicians, albeit not gastroenterologists or surgeons. However, if we add the very high prevalence rate, of more than 10% of the adult population, the overall long length of conservative medication-based therapy and the severity of complications after surgery, it becomes clear that this is truly a disease that should change the perspective.
To provide clinicians, both gastroenterologist and colorectal surgeons, the proper tools to better outlay the treatment options factoring in patients’ comorbidities, chronic medication and the severity of hemorrhoidal disease.
To compare the overall clinical results of different surgical techniques on patients with grade II and above of HD and different comorbidities with documented impact in the development and evolution of HD.
We developed a multicentric retrospective study that covers 10 years of treating patients with hemorrhoidal pathology, in two major clinics, a private-based medical facility and a state-owned hospital. Between January 2011 and December 2021, a total of 10.940 patients have been enrolled and treated for hemorrhoidal disease, in various stages and with different methods, ranging from medical options to surgical ones. The study also recorded full demographic details, classification of hemorrhoidal pathology before surgery as well as a comprehensive comorbidities panel, including inflammatory bowel disease, anticoagulant medication, and liver cirrhosis, all medical conditions with documented impact with impact on HD. Other important details such as length (in minutes) of surgical procedure, duration of hospitalization, return to work time, type of complications developed and their time of onset, in respect to the initial procedure have been recorded. Regarding the surgical procedures we noted open hemorrhoidectomy (OH) with a modified OH, stapled hemorrhoidopexy (SH) and rubber band ligation (RBL) with infrared coagulation (IRC). For comparison purposes we constasted our data with the ones in international literature by performing a review consisting in a custom interrogation of PubMed and PubMed Central for the terms “hemorrhoid” and “postoperative” and “complications”, for the past 20 years (2002-2022) and selecting clinical trials, meta-analysis, randomized control trials, reviews, and systematic reviews as scientific sources, resulting in a list of 1263 articles.
Our study recorded a total of 10.940 patients diagnosed with HD, 8144 patients (74%) receiving conservative, medication-based treatment and 2796 being treated with minimally invasive procedures (2097 patients) or with invasive techniques (699 patients). Regarding the treatment, patients with grade I pathology (74%) received conservative therapy. Non-surgical treatment with RBL and IRC was applied to patients with grade II HD and all patients with grade II that also had at least one grade III hemorrhoidal dilation plus all grade III (19%). Surgical treatment consisting of OH, SH or OH with ligasure, 6% of cases, was reserved for patients with grade III HD that also had at least one grade IV dilation, and patients with fully grade IV pathology.
We strongly believe that a complete and efficient treatment of hemorrhoidal disease should be a highly tailored one, based on a very good clinical assessment of the patient. Reviewing our lot of patients and procedures, we think that open hemorrhoidectomy by high-energy vessel-sealing platforms may induce significant anal stricture and should be avoided, even though they provide a better intraoperative bleeding control and overall shorter operating times. As demonstrated by clinical data obtained in this study, we believe that our modified Milligan Morgan OH technique has many advantages, even though arguably marginal, over the standard OH, but more than enough to possibly make it a routine procedure in patients with grade IV HD.
Further study that includes patients with HD and HIV-induced immunodeficiency is in order, since this is a documented risk factor that increases the chances of anorectal infections therefore the postoperative development can be very unpredictable and may render different results then the ones in our study. Also, a full manometric evaluation, both prior and in the postoperative state can give us a more detailed information regarding the actual impact of different surgical techniques and tools, especially in regard to high-energy platforms.