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The aim of these evidence-based guidelines is to present a consensus position from members of the Italian Unitary Society of Colon-Proctology (Società Italiana Unitaria di Colon-Proctologia, SIUCP) on the diagnosis and management of hemorrhoidal disease, with the goal of guiding physicians in the choice of the best treatment option. A panel of experts was charged by the Board of the SIUCP to develop key questions on the main topics related to the management of hemorrhoidal disease and to perform an accurate and comprehensive literature search on each topic, in order to provide evidence-based answers to the questions and to summarize them in statements. All the clinical questions were discussed by the expert panel in multiple rounds through the Delphi approach and, for each statement, a consensus among the experts was reached. The questions were created according to PICO (patients, intervention, comparison, and outcomes) criteria, and the statements were developed adopting the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) methodology. In cases of grade 1 hemorrhoidal prolapse, outpatient procedures including hemorrhoidal laser procedure and sclerotherapy may be considered the preferred surgical options. For grade 2 prolapse, nonexcisional procedures including outpatient treatments, hemorrhoidal artery ligation and mucopexy, laser hemorrhoidoplasty, the Rafaelo procedure, and stapled hemorrhoidopexy may represent the first-line treatment options, whereas excisional surgery may be considered in selected cases. In cases of grades 3 and 4, stapled hemorrhoidopexy and hemorrhoidectomy may represent the most effective procedures, even if, in the expert panel opinion, stapled hemorrhoidopexy represents the gold-standard treatment for grade 3 hemorrhoidal prolapse.

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BACKGROUND: To determine 1-year postoperative recurrence rates, postoperative pain and complication rates of transanal open haemorrhoidopexy applied also in grade IV haemorrhoids. METHODS: Single-centre retrospective observational study without control group. The primary outcome was recurrence rate after 1 year postoperatively. Secondary outcomes were length of postoperative pain, use of opiates and postoperative complications. The recurrence rate was assessed with the Sodergren haemorrhoid symptom severity score questionnaire. For information on the early postoperative period, a retrospective chart review based on the routine 3-month clinical follow-up was done. RESULTS: 135 consecutive patients with haemorrhoids Goligher grades II-IV were operated with transanal open haemorrhoidopexy. 88 patients (65%) consented to participate in the study when approached later via mail. 23% of patients had haemorrhoids Goligher grade IV. 15 patients (17%) needed a second transanal open haemorrhoidopexy for residual haemorrhoidal prolapse. The recurrence rate of prolapsing haemorrhoids was 15% (13 patients) 1 year postoperatively. 21% of patients reported no postoperative pain, 54% described pain for a duration of up to 1 week and 22% for up to 2 weeks. Two patients reported a longer duration of pain of 3 and 4 weeks, respectively. No complications grade Clavien-Dindo III or higher were detected. CONCLUSION: The results of our study indicate that transanal open haemorrhoidopexy has a recurrence rate comparable to traditional haemorrhoidectomy including grade IV haemorrhoids and is associated with less pain and tissue damage. A randomized controlled trial may provide further support for the routine application of this method, but may pose challenges.

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BACKGROUND: Aluminum potassium sulfate and tannic acid (ALTA) is an effective sclerosing agent for the treatment of internal hemorrhoids. ALTA therapy with rectal mucopexy (AM) is a new approach for treating hemorrhoidal prolapse. This study investigated the midterm outcomes of AM surgery in patients with hemorrhoids. METHODS: Patients with grade III hemorrhoids who underwent AM surgery were enrolled in this retrospective analysis of prospectively collected data from a single institution. Cumulative success rates, postoperative symptoms, including pain scores, analgesic requirements, and postoperative complications, and patient satisfaction were assessed. RESULTS: The median number of ALTA injection procedures was 3 (range 1-4), and the median total injection dose was 19 mL (range 7-32 mL). The median number of mucopexy procedures was 2 (range 1-4). The median postoperative pain score (0 = no pain at all, 10 = worst pain imaginable) at rest or during defecation were ≤2. The total dose of analgesics administered during the first two weeks after surgery was 1 (range 0-25). Six patients (5.3%) showed postoperative complications: five showed Clavien-Dindo (C-D) grade I and one showed C-D grade IIIa complications. Cumulative success rates at one, three, and five years were 96.5%, 85.3%, and 85.3%, respectively. Patient satisfaction scores, which were assessed using a 10-point scale, were ≥9 at each postoperative year. CONCLUSIONS: AM surgery is an effective non-excisional surgery with satisfactory mid-term results for grade III hemorrhoids, and is associated with lower complication rates, postoperative analgesic requirements, and higher patient satisfaction.

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Background: 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. Objective: To compare two groups of patients (treated with DG-HAL or HAL) in terms of recurrence risk and patients' satisfaction grade. Methods: 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. Results: 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). Conclusions: In our study, the use of DG did not reduce recurrence risk. Operative time was significantly increased in the DG-HAL group.

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Introduction: 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. Materials and methods: 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. Results: 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). Conclusions: 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.

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PURPOSE: Hemorrhoids are the most common benign anorectal diseases. Mucopexy strengthens the anal canal mucosa, which can be performed alone or in combination with Doppler-guided hemorrhoidal artery ligation (DG-HAL). In this study, we compared the postoperative complications between simple mucopexy plus HAL with and without a Doppler guide. METHODS: This study was performed as a single-blinded randomized clinical trial. Patients referred to a tertiary colorectal referral clinic with grades 3 and 4 hemorrhoids who were candidates for surgical intervention entered the study. Thirty-six patients were randomly divided into 2 groups. Group A including 18 patients underwent mucopexy and DG-HAL and the other 18 patients (group B) underwent standard mucopexy and HAL without a Doppler guide. Postoperative pain score and the duration of oral analgesic consumption were recorded. Additionally, postoperative symptoms and complications were recorded and compared between the 2 methods. RESULTS: There was no significant difference between the 2 groups in terms of pain score and the duration of postoperative analgesic consumption as well as the incidence of postoperative complications. Besides, the primary grade of hemorrhoids was not significantly associated with recurrence, but there was a significant association between body mass index and Wexner score (WS) with recurrence. The mean WS of patients showed a significant decrease in both groups postoperatively. However, the rate of WS reduction was not remarkably different between the 2 groups. CONCLUSION: Simple mucopexy with blind HAL (without Doppler guide) might be considered for the treatment of grades 3 and 4 hemorrhoids effectively.

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Transanal hemorrhoidal dearterialization (THD) is a minimally invasive procedure that has gained popularity as a treatment for symptomatic hemorrhoids. It involves ligating the arterial blood supply to the hemorrhoidal plexus. Compared to conventional ligation or resection, THD is associated with less postoperative bleeding and pain, allowing for same-day surgery discharge. Horseshoe abscess is a rare but known complication of anorectal surgery, characterized by an abscess that extends around the anal canal, often involving the ischiorectal fossa and adjacent structures. Although horseshoe abscesses have been reported after various anorectal surgeries, including hemorrhoidectomy, their occurrence following THD has not been well-documented in the literature. A 72-year-old male underwent THD for rectal prolapse with internal hemorrhoids and presented to the hospital on postoperative day 6 with severe rectal pain. A computed tomography (CT) scan revealed a large complex horseshoe perirectal abscess with fluid and air and significant rectal wall thickening. A rectal examination under anesthesia confirmed the presence of purulent drainage from the anus, and surgical drainage of the abscess was performed. The patient received antibiotics and analgesics and experienced a favorable recovery. The exact pathophysiology of a horseshoe abscess following THD remains unclear, and the incidence and risk factors associated with this complication are not well-established. Moreover, there has yet to be a consensus on the optimal management of horseshoe abscesses after THD, whether through surgical or medical approaches. This case emphasizes the importance of considering horseshoe abscess as a potential complication of THD and highlights the need for further research to understand better its incidence, risk factors, and optimal management strategies.

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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.

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PURPOSE: Aluminum potassium sulfate and tannic acid (ALTA; Zion, Mitsubishi Pharma Corp.) is an effective sclerosing agent for internal hemorrhoids. ALTA therapy with a rectal mucopexy (AM) is a new approach for treating hemorrhoidal prolapse. This study compared the early postoperative outcomes of AM surgery with Doppler-guided transanal hemorrhoidal dearterialization and mucopexy (DM) in patients with third-degree hemorrhoids. METHODS: AM surgery was performed on 32 patients with grade III hemorrhoids and was compared with a cohort of 22 patients who underwent DM surgery in a previous randomized controlled trial. RESULTS: The pain scores during defecation were significantly lower in the AM patients beginning 4 days after surgery. The total use of analgesics 2 weeks postoperatively was significantly lower in the AM patients than in the DM patients (3.5 tablets [range 1.6-5.5] vs. 7.6 tablets [range 3.3-11.9], P=0.04). The length of operation, blood loss, and incidence of postoperative complications were significantly lower in the AM patients than in the DM patients. During 12 months follow-up, recurrence of prolapse occurred in 1 patient who underwent AM surgery. CONCLUSION: AM surgery is effective, with lower complication rates and postoperative analgesic requirements, and is a less invasive treatment for patients with grade III hemorrhoids compared to DM surgery.

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OBJECTIVE: To compare the immediate and long-term results of surgical treatment of hemorrhoidal disease (GD) stage II-III using two methods of identification of hemorrhoidal arteries (HA) with their subsequent ligation and mucopexy. MATERIAL AND METHODS: A prospective, randomized, controlled, single-center study was conducted to evaluate the effectiveness of HA ligation with and without Doppler navigation. The study included 120 patients: group A - Doppler-guided ligation (n=60) and group B - ligation without ultrasound (n=60). RESULTS: GD stage II was found in 27 patients of the group A and 30 patients of the group B (p=0.4). Mean number of ligated HA in the group A was 3.36, in the group B - 2.83 (p=0.062). Mean number of mucopexy was 3.2 and 3.5, respectively (p=0.8). Mean follow-up period was 8.3±2.1 and 8.1±1.9 months, respectively (p=0.96). Relapse of all preoperative symptoms was registered in 1 patient (1.6%) in the group A. Intermittent bleeding was observed in 5 (8.3%) and 3 (5%) patients, respectively (p=0.71). Periodic hemorrhoid prolapse (GP) occurred in 6 (10%) and 4 (6.6%) respondents, respectively (p=0.74). VAS score of pain syndrome after 2 months and later was 0 - 1 points (p=1.0). Most of patients in both groups (group A - 89%, group B - 94%; p=0.7) noted that surgery did not disrupt their usual lifestyle and relieved from symptoms of GD. CONCLUSION: There are no significant advantages of Doppler-guided HA ligation compared to palpation regarding incidence of hemorrhoid prolapse (p=0.74) and hemorrhoidal bleeding (p=0.71). Pain syndrome (p=0.24), incidence of postoperative complications (p=0.51) and relapses (p=0.31) showed comparable safety of both techniques.

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BACKGROUND: The aim of this study was to evaluate the outcome of hemorrhoidal surgery in patients with inflammatory bowel disease (IBD) undergoing surgery at our center. METHODS: All adult patients with IBD undergoing hemorrhoidal surgery in our department between November 1, 2013 and July 7, 2020 were included in the study. At the time of surgery, the patients' IBD was in clinical, biological and endoscopic remission, and none of the patients had specific primary anoperineal lesions. RESULTS: We included 25 patients (48% female) with a mean age 48 years (± 13.1 years). There were 13 cases of CD (52%) and 12 of ulcerative colitis (UC). Pharmacological and instrumental hemorrhoidal treatment had failed in all patients. The CD lesions were exclusively ileal (77%) or ileocolic (23%). The surgical procedures performed for CD were mono-hemorrhoidectomy in three patients (21.4%), tripedicular hemorrhoidectomy in six patients (42.9%), and artery ligations with mucopexy in five patients (35.7%). UC was rectal (16.7%), rectosigmoid (66.7%), or pancolic (16.6%). The surgical procedures performed for UC were a tripedicular hemorrhoidectomy in ten patients (83.3%) and artery ligations with mucopexy in two patients (16.7%). The mean duration of postoperative follow-up was 15.1 months. None of the patients was lost to follow-up. The mean time to wound healing after resection was 71.1 days (± 21 days) for patients with CD and 56.9 days (± 6.7 days) for patients with UC (p = 0.05). Postoperative complications were reported for four patients with CD (28.8%) and two patients with UC (16.7%). There was no suppuration, stenosis, or anal incontinence sequelae. CONCLUSIONS: Hemorrhoidal surgery resulted in a non-negligible frequency of complications in our series of IBD patients, especially in those with CD. Caution is, therefore, still necessary in this patient population.

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The adjunct of a mucopexy to conventional dearterialization has become a routine part of the transanal hemorrhoidal dearterialization procedure in order to facilitate the management of the prolapsing component and has helped to expand the indications of this technique to more advanced stages of hemorrhoidal disease. A simple technical modification of THD with targeted mucopexy (TM), called Anolift, is described. The aim of the study was to evaluate the safety and effectiveness of this technical variation. The procedure consisted of two parts: one aimed at the dearterialization and the other concentrated on the management of the prolapsing component. Once all the arteries were identified and transfixed an Anolift targeted mucopexy was performed using a continuous barbed suture with a synthetic absorbable monofilament (Polydioxanone) 2/0 Filbloc (Assut Europe) stitch mounted on a 4/8 30 mm needle. Severity of hemorrhoidal symptoms was scored from 0 to 20 using a dedicated questionnaire: the Hemorrhoidal Assessment Severity Score (HASS). From May 2018 to November 2020, 60 patients with hemorrhoidal disease (HD) underwent a THD Anolift procedure. Three patients experienced severe post-operative pain and 10 (23%) suffered with difficulty in evacuation. The median follow-up period was 15.5 months (range 2-32 months). The mean HASS changed from 16.43 pre-operatively to 1.95 post-operatively (p < 0.0001). Pre-operative HASS very strongly correlated with the degree of hemorrhoids (p < 0.001), while there was no correlation between the pre-operative HASS or the degree of hemorrhoids and the post-operative HASS (p = 0.163). There was no significant difference in predicted post-operative HASS according to the pre-operative HD stage. One patient (1.6%) with circumferential IV hemorrhoids had a recurrence and required a further THD. Two patients had excision of skin tags (3%). The Anolift technique is safe and effective for the management of HD even in patients with advanced stages.

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PURPOSE: A wide variety of methods has been proposed for treating hemorrhoidal disease. The aim of the study is to assess the safety and effectiveness of hemorrhoidal artery ligation with rectoanal repair (HAL-RAR). METHODS: Retrospective study from January 2010 to November 2019 of patients who underwent HAL-RAR for grade II, resistant to conservative treatment, and grades III and IV hemorrhoidal disease. Demographics, degree of disease, hospital stay, postoperative pain, complications, and recurrence were recorded. Patients were followed up at postoperative days 1 and 8 and at 1, 6, and 12 months. RESULTS: A total of 105 patients (60 men, 45 women) underwent HAL-RAR. Median age was 49 (range, 20-86) years. Two patients with hemorrhoidal thrombosis underwent emergent excision of the hemorrhoid. Median length of hospital stay was 2 (range, 1-13) days. Patients reported median visual analog scale pain score 3 (range, 1-5) on the 1st postoperative day. At 1 month, no patient reported pain, 84.76% of patients confirmed complete resolution of symptoms, while complication rate was 7.61%: 2 patients presented urinary retention, 3 dyschezia, 2 bleeding, and 1 hemorrhoidal necrosis. At 6 months, 2 patients presented mild symptoms and 7 recurrence. At 12 months, 92.4% of patients experienced complete resolution of symptoms, 2 patients intermittent bleeding, and 2 recurrence. Overall recurrence and re-intervention rate were 8.57% rate and 10.5%, respectively. CONCLUSION: HAL-RAR is a safe and effective minimal invasive operative technique related to a high percentage of success, low complication, and recurrence rates. Long-term follow-up is lacking and would better establish the results of this technique. TRIAL REGISTRATION: Trial registration number NCT04778124 Date of registration 26/02/2021 "retrospectively registered".

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BACKGROUND: Although conventional open haemorrhoidectomy and stapled haemorrhoidectomy are effective procedures, they can lead to significant post-operative pain with risks to continence. Current evidence favours transanal haemorrhoidal dearterialisation (THD) and targeted mucopexy to be an efficacious alternative to conventional modalities. Our aim was to assess the midterm outcomes following THD. METHODS: Prospective data was collected for patients undergoing day case THD under a single consultant over a 9-year period (March 2009 to February 2018). Data collected included: intra-operative findings, post-operative pain (defined as requirement of analgesia in recovery), post-operative complications and requirement of further procedures. RESULTS: Over this time period, 271 patients underwent THD, with 203 (74.9%) patients also undergoing targeted mucopexy for 2nd to 4th degree haemorrhoids. Only 4 (1.5%) patients suffered from post-operative complications, including significant bleeding (n = 1), urinary retention (n = 1) and constipation (n = 2). Post-operative pain was identified in only 10 (3.7%) patients; eight of which had simultaneously undergone an additional procedure (e.g. excision of anal polyps and skin tags). Only 5 (1.8%) patients were identified that required further haemorrhoidal invasive intervention subsequently. CONCLUSIONS: These results are comparable with national data and demonstrate that THD is a safe procedure for symptomatic haemorrhoids with minimal morbidity.

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Several minimally invasive surgical procedures have been recently developed to treat hemorrhoids without any excision. About 25 years ago, a non-excisional procedure providing doppler- guided ligation of the hemorrhoidal arteries has been proposed - named "hemorrhoidal dearterialization". The original technique has been modified over the years, and indications were expanded. In particular, a plication of the redundant and prolapsing mucosa/submucosa of the rectum (named "mucopexy") has been introduced to treat hemorrhoidal prolapse, without excision of the hemorrhoidal piles. At present, the THD® Doppler procedure is one of the most used techniques to treat hemorrhoids. Aim of this technique is to realize a target dearterialization, using a Doppler probe with the final purpose to reduce the arterial overflow to the hemorrhoidal piles. In the case of associated hemorrhoidal prolapse, a mucopexy is performed together with Doppler-guided dearterialization. The entity and circumferential extension of the hemorrhoidal prolapse guide the mucopexy, which can be considered tailored to a single patient; the dearterialization should be considered mandatory. Advantages of this surgical technique are the absence of serious and life-threatening postoperative events, chronic complications, and limited recurrence risks. The impact of the procedure on the anorectal physiology is negligible. However, careful postoperative management is mandatory to avoid complications and to guarantee an improved long-term outcome. Therefore, regular physiologic bowel movements, excessive strain at the defecation and strong physical activity are advisable.

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BACKGROUND: Minimally-invasive treatments for hemorrhoids should be encouraged as they cause low morbidity, reasonable discomfort and quicker return to work. According to the "vascular theory", hemorrhoidal disease is mainly caused by blood overflow into hemorrhoidal plexus deriving from the superior hemorrhoidal arteries. INTRODUCTION: Many different procedures have been described in the literature with the common goal of reducing the blood flow into the hemorrhoidal piles. 'HeLP' (Hemorrhoids Laser Procedure) is a novel form of dearterialization to treat patients suffering from symptomatic hemorrhoids. METHODS: The procedure consists of the closure of the terminal branches of the superior rectal artery approximately 2-3 cm above the dentate line by means of laser shots originated by a diode laser platform. The arteries, at that level, have variable location and distribution. Therefore, a doppler probe set at the frequency of 20MHz helps identifying the arteries that would be missed otherwise. The laser beam is well tolerated by patients. For this reason, anesthesia is not required in most cases and the procedure allows a quick return to daily activities. In the case of concomitant severe mucosal prolapse, laser treatment can be combined with suture mucopexy. Three to six running sutures allow a complete lifting of hemorrhoidal piles, securing a long-term resolution of symptoms. RESULTS: 'HeLP' is indicated in patients with symptomatic hemorrhoids where conservative treatment failed and when mucosal prolapse is scarce or not symptomatic. The addition of mucopexy to laser treatment (HeLPexx) contributes to the overall resolution of symptoms when mucosal prolapse is an issue. CONCLUSION: Emborrhoid is another novel, 'hi-tech' form of selective dearterialization used in selected cases of hemorrhoids where the main symptom is bleeding. It is generally used in cases where surgery is contraindicated due to severe concomitant diseases.

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ABSTRACT Background: Transanal hemorrhoidal dearterialization (THD) is safe and effective minimally invasive treatment for hemorrhoidal disease, but reports regarding recurrence and postoperative complications (pain and tenesmus) vary significantly. Aim: To evaluate if selective dearterialization and mucopexy at the symptomatic hemorrhoid only, without Doppler guidance, achieves adequate control of the prolapse and bleeding and if postoperative morbidity is reduced with this technique. Methods: Twenty consecutive patients with grade II and III hemorrhoids were treated with this new approach and were evaluated for postoperative complications and recurrence. Results: Control of prolapse and bleeding was achieved in all patients (n=20). Postoperative complications were tenesmus (n=2), external hemorrhoidal thrombosis (n=2) and urinary retention (n=2). After a mean follow-up of 13 months no recurrences were diagnosed. Conclusion: Selective dearterialization and mucopexy is safe and achieves adequate control of prolapse and bleeding and, by minimizing sutures in the anal canal, postoperative morbidity is diminished. Doppler probe is unnecessary for this procedure, which makes it also more interesting from an economic perspective.

RESUMO Racional: O tratamento da doença hemorroidária pela técnica de THD (Transanal Hemorrhoidal Dearterialization) é minimamente invasivo e tem se mostrado seguro e eficiente. No entanto, dados sobre a recorrência e complicações (dor e tenesmo) no pós-operatório são muito variáveis. Objetivo: Avaliar se a desarterialização e mucopexia seletiva, sem o uso de Doppler, é suficiente para o controle de sintomas e se a morbidade pós-operatória é menor com esta técnica. Métodos: Vinte pacientes foram tratados com essa técnica e avaliados sobre controle de sintomas, morbidade pós-operatória e recorrência. Resultados: Controle do prolapso e sangramento foi observado em todos pacientes (n=20). Complicações pós-operatórias foram: tenesmo (n=2), trombose hemorroidária externa (n=2), retenção urinária (n=2). Após um seguimento médio de 13 meses, nenhuma recorrência foi detectada. Conclusões: O procedimento de desarterialização e mucopexias seletivas é seguro e eficiente em termos de controle do prolapso e sangramento. Esta técnica resulta em menor morbidade cirúrgica, uma vez que diminui o número de suturas no canal anal, resultando em menos dor e tenesmo pós-operatório. Para este procedimento o uso de ultrassom Doppler é desnecessário, o que diminui custos e o torna mais atrativo do ponto de vista econômico.

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BACKGROUND: Currently, there is no consensus regarding the best treatment option in recurrent haemorrhoidal disease (HD), due to a lack of solid evidence. The Napoleon trial aims to provide high-level evidence on the comparative effectiveness and cost-effectiveness of repeat rubber band ligation (RBL) versus sutured mucopexy versus haemorrhoidectomy in patients with recurrent HD. METHODS: This is a multicentre randomized controlled trial. Patients with recurrent HD grade II and III, ≥18 years of age and who had at least two RBL treatments in the last three years are eligible for inclusion. Exclusion criteria include previous rectal or anal surgery, rectal radiation, pre-existing sphincter injury or otherwise pathologies of the colon and rectum, pregnancy, presence of hypercoagulability disorders, and medically unfit for surgery (ASA > III). Between June 2020 and May 2022, 558 patients will be randomized to receive either: (1) RBL, (2) sutured mucopexy, or (3) haemorrhoidectomy. The primary outcomes are recurrence after 52 weeks and patient-reported symptoms measured by the PROM-HISS. Secondary outcomes are impact on daily life, treatment satisfaction, early and late complication rates, health-related quality of life, costs and cost-effectiveness, and budget impact. Cost-effectiveness will be expressed in societal costs per Quality Adjusted Life Year (QALY) (based on EQ-5D-5L), and healthcare costs per recurrence avoided. DISCUSSION: The best treatment option for recurrent HD remains unknown. The comparison of three generally accepted treatment strategies in a randomized controlled trial will provide high-level evidence on the most (cost-) effective treatment. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT04101773.

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This study aims to share the results of haemorrhoidal artery ligation under direct vision in the management of symptomatic haemorrhoids. We conducted a case series of 70 patients at Combined Military Hospital Rawalpindi & Quetta, from January 2015 to October 2017. All patients underwent Haemorrhoidal Artery Ligation (HAL) and Recto Anal Repair (RAR). Ligation of superior haemorrhoidal artery was done under direct vision following manual palpation. Patients were followed up postoperatively at 1, 3 and 6 months. At 1 month follow up, all 70 (100%) patients were pain free. Post operative bleeding was observed in 7 (10%) patients but did not require surgical intervention. Sixty two (89%) patients were able to return to their daily activities 1 week after surgery and 57 (81%) resumed military duties or joined their work place at 2 weeks. 70 (100%) patients were asymptomatic and 45 (64%) highly satisfied with their surgery at 3 months. This increased to 53 (75%) at 6 months. 48 (69%) said that they would recommend this procedure to someone else. Prolapse recurrence was observed in 1(1.42%) patient 6 months post operatively which was dealt by band ligation. All patients completed follow-up at 1, 3 and 6 months. HAL is a simple yet safe technique with few complications, acceptable patient satisfaction and early return to work.

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