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Background: Hemorrhoids are very common in patients with human immunodeficiency virus (HIV) infection. The risk of postoperative infection is significantly greater in HIV-positive patients than in HIV-negative individuals, and the wound healing time is significantly prolonged. This study aimed to investigate the role of HIV-associated hemorrhoids from the perspective of vascular smooth muscle cell (VSMC) function., Methods: A total of 24 hemorrhoid tissue samples (note: grade IV hemorrhoids were absence) were collected and subjected to Masson staining to evaluate fibrosis in this study. mRNA and protein levels were monitored by qPCR and WB analysis, respectively. Immunofluorescence was conducted to evaluate PKG1 and α-SMA expression. To establish a cell model in vitro, VSMCs were stimulated with envelope glycoprotein (gp) 120, which is a type of HIV envelope protein. Cell proliferation was assessed via a CCK-8 assay and EdU staining. Moreover, a wound healing assay was performed to assess cell migration., Results: Our data confirmed that fibrosis was present in hemorrhoid tissues from HIV-infected patients and that PKG1 expression was upregulated. Moreover, the administration of HIV gp120 promoted the proliferation and migration of VSMCs. Similarly, fibrosis-related markers (α-SMA, MMP2, MMP3, and TIMP1) were markedly upregulated. However, silencing PKG1 inhibited the proliferation, migration, and expression of fibrosis-related markers in gp120-challenged VSMCs., Conclusion: The present research revealed that PKG1 regulated the proliferation, migration, and fibrosis of VSMCs, thereby exerting detrimental effects on HIV-associated hemorrhoids., (© 2024. The Author(s).)

Purpose: To describe the clinical presentation and urodynamic findings in detrusor underactivity (DU) patients and investigate the association between DU and straining related complications such as pelvic organ prolapse (POP), inguinal hernia, and hemorrhoids., Methods: We retrospectively reviewed all consecutive patients who underwent urodynamic studies (UDS) from 2012 to 2023, divided into two groups: those with evidence of DU (n = 573), and control subjects with normal voiding parameters (n = 522). Exclusion criteria were patients who lacked sufficient data, those with obstructive voiding parameters, and those who had received intravesical botulinum toxin injections within the previous nine months. Demographic information, clinical presentation, straining related complications, and UDS findings were compared between the two groups using univariate statistical analysis., Results: The male DU group had a statistically significant higher prevalence of spinal disease and previous cerebrovascular accidents, while the female DU group had a statistically significant higher prevalence of spinal disease, multiple sclerosis, diabetes, previous colorectal surgery, previous transabdominal gynecological surgery, POP surgery, and recurrent UTIs. Female DU patients had a higher prevalence of pronounced vaginal bulging symptoms, recurrent POP, inguinal hernia, and hemorrhoids. The predominant LUTS were voiding symptoms (81.2% in males and 77.9% in females), followed closely by storage symptoms (66.2% in males and 74.7% in females). The median Qmax, PdetQmax, and PVR were 6 ml/sec, 18 cmH2O, 190 ml for male DU patients, and 8 ml/sec, 11 cmH2O, and 200 ml for female DU patients, respectively., Conclusion: Risk factors for DU that were identified include age, neurological diseases (spinal disease, CVA in men, MS in women), diabetes and transabdominal surgery (colorectal, gynecological) that can cause pelvic denervation in women. DU patients commonly present with both voiding and storage symptoms. There is approximately twice the risk of having POP surgery and inguinal hernia, an eight-fold risk of hemorrhoids, and a three-fold risk of recurrent UTIs for females. This is thought to be secondary to increased intra-abdominal pressure during urinary straining., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objectives: Upper gastrointestinal bleeding (GIB) in patients has been well-characterized in liver cirrhosis but studies on lower GIB are limited. The clinical characteristics, management and outcomes in patients with and without liver cirrhosis was compared to determine the overall features of GIB in patients with liver cirrhosis compared with non-cirrhotics., Methods: A retrospective study on cirrhotics hospitalized for GIB 2010-2021, matched with control group of non-cirrhotics (1:4) for upper vs. lower GIB. Patients with overt bleeding leading to hospitalization were included., Results: Overall, 396 patients had cirrhosis, 267 (67%) men, median age 62, alcoholic etiology 177/396 (45%), median MELD 12 (range 6-32). Overall 102 cirrhotics had GIB, matched with 391 non-cirrhotics. Overall 87 (85%) cirrhotic patients had upper and 15% lower GIB. Compared to non-cirrhotics, the cause of GIB was more commonly acute variceal bleeding (AVB) (42% vs. 1%), hemorrhoids 40% vs. 6% ( p  = 0.002), less commonly gastric ulcer 13% vs. 31% ( p  < 0.001), duodenal ulcer 9% vs. 29% ( p  < 0.001), 5% of cirrhotics used NSAIDs vs. 26% of controls ( p  < 0.001). Rebleeding occurred in 14% of cirrhotics vs. 3% in controls ( p  < 0.001). Only one cirrhotic patient (1%) died from GIB vs. 0.8% of controls within 45 days. Overall mortality 45 days after hospitalization was 10% in cirrhotics vs. 5% in controls ( p  < 0.001)., Conclusions: Bleeding from gastric and duodenal ulcers were less common in cirrhotics than in controls. Bleeding from hemorrhoids was more common in cirrhotics. Mortality due to GIB was low in both groups but overall mortality was significantly higher in cirrhotics.

Introduction: hemorrhoidal disease and anal fissure are the two most frequent entities within benign anal pathology, both of which have a negative impact on quality of life. To date, there is no specific questionnaire in Spanish to assess the impact on quality of life in patients suffering from these conditions., Objective: the aim of this study was to validate a questionnaire in Spanish for this purpose, adapting it to our daily clinical practice., Material and Methods: the HEMO-FISS-Quality of Life Questionnaire (HEMO-FISS-CdV) is the Spanish version of the original HEMO-FISS-Quality of Life Questionnaire (HEMO-FISS-QoL) by Abramowitz. The questionnaire consists of 23 items organized in four dimensions (physical, psychological, defecation and sexuality). The reliability of the new tool was assessed by determining internal consistency using Cronbach's alpha and Guttman's coefficient. It was also correlated with the quality of life questionnaire SF12 Health Questionnaire version 2 (SF12v2)., Results: the Cronbach's alpha obtained for our questionnaire (HEMO-FISS-CdV) was 0.951 (CI 95 % ± 0.016), with a range between 0.935 and 0.967. The Guttman two-half coefficient had a value of 0.910. Patients with internal hemorrhoids, anal fissure or both had higher values on the HEMO-FISS-CdV questionnaire than patients without internal hemorrhoids, and these differences were significant (p < 0.05)., Conclusion: both diseases have a negative impact on quality of life. The HEMO-FISS-CdV provides a tool in Spanish that easily and specifically assesses the impact of hemorrhoidal disease and anal fissure on quality of life.

Abstract: Perianal ulcers (PAUs) related to antihemorrhoidal product use have been recently reported in the literature through a few case reports. However, other etiologies of PAU must be ruled out, including infectious disease, inflammatory disease, malignancy, pressure injuries, radiotherapy, and other topical drugs. In this report, the authors describe two cases of PAUs due to an antihemorrhoidal ointment. In case 1, a 68-year-old woman with a history of hemorrhoids presented with PAUs after using an antihemorrhoidal ointment for 2 months. The ulcers were assessed through a histopathologic study and treated with calcium alginate dressings, with complete re-epithelialization occurring after 2 months. In case 2, a 58-year-old woman with a history of hemorrhoids developed painful PAUs while using an antihemorrhoidal ointment for 2 months. No other probable cause was found, and the ulcers were treated by discontinuing the ointment. The ulcers showed marked improvement, and complete re-epithelialization occurred after 6 weeks without additional treatment., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

BACKGROUND Severe anemia caused by hemorrhoidal hematochezia is typically treated preoperatively with reference to severe anemia treatment strategies from other etiologies. This retrospective cohort study included 128 patients with hemorrhoidal severe anemia admitted to 3 hospitals from September 1, 2018, to August 1, 2023, and aimed to evaluate preoperative blood transfusion requirements. MATERIAL AND METHODS Of 5120 patients with hemorrhoids, 128 (2.25%; male/female: 72/56) experienced hemorrhoidal severe anemia, transfusion, and Milligan-Morgan surgery. Patients were categorized into 2 groups based on their preoperative hemoglobin (PHB) levels after transfusion: PHB ≥70 g/L as the liberal-transfusion group (LG), and PHB <70 as the restrictive-threshold group (RG). The general condition, bleeding duration, hemoglobin level on admission, transfusion volume, length of stay, immune transfusion reaction, surgical duration, and hospitalization cost were compared between the 2 groups. RESULTS Patients with severe anemia (age: 41.07±14.76) tended to be younger than those with common hemorrhoids (age: 49.431±15.59 years). The LG had a significantly higher transfusion volume (4.77±2.22 units), frequency of immune transfusion reactions (1.22±0.58), and hospitalization costs (16.69±3.31 thousand yuan) than the RG, which had a transfusion volume of 3.77±2.09 units, frequency of immune transfusion reactions of 0.44±0.51, and hospitalization costs of 15.00±3.06 thousand yuan. Surgical duration in the LG (25.69±14.71 min) was significantly lower than that of the RG (35.24±18.72 min). CONCLUSIONS Patients with hemorrhoids with severe anemia might require a lower preoperative transfusion threshold than the currently recognized threshold, with an undifferentiated treatment effect and additional benefits.

High-grade hemorrhoids are usually recommended to receive operational treatments. However, these traditional surgeries are associated with severe postoperative pain. A procedure for prolapse and hemorrhoids (PPH), a circular staple device, has been developed to improve short-term outcomes, including reducing the severity of postoperative pain. PPH, compared to conventional surgery, has been associated with the incidence of anatomical anal stenosis. The causes of stenosis after PPH are not yet clear. We first analyzed the complications of our patients with PPH, and then developed a rat model to verify the tension force of PPH using Hematoxylin-eosin, Masson's trichrome, immunohistochemistry, and immunofluorescence staining. Our clinical data showed that PPH significantly improved postoperative pain, but that it resulted in higher incidences of complications, including anal stenosis, than hemorrhoidectomy. We simulated the status of PPH and developed a rat model to verify PPH's tension force, including the scarring area and the deposition of proinflammatory factors, angiogenic factors, and fibrotic factors. The tension wound histological data showed more extensive granulation tissue and inflammatory cell infiltration and a thicker epidermis than the control group on day 12 post-operation and tension treatment. In addition to IL-1β and IL-10 cytokines on day 3 and IL-1β, IL-6, and IL-10 cytokines on day 12 post-operation in the tension group, two angiogenic factors, CD31 and VEGF-A, were found to have a more significant expression on day 7 post-operation in the tension group. The mean scar area was larger and the distribution of fibrotic proteins (collagen 1, α-SMA, CTGF, and MMP2) in the tension group was significantly broader than in the control on day 12 post-operation and tension treatment. Based on the findings of our animal model, the development of a lesser tensile force for PPH to decrease the deposition of proinflammatory factors, angiogenic factors, and fibrotic factors is urgently required.

Abstract: Hemorrhoids are normal anatomical structures in the anus. When symptomatic, they prompt medical attention due to pain, rectal bleeding, and discomfort. Treatment includes dietary modifications, rubber band ligations, sclerotherapy, cryotherapy, or hemorrhoidectomy. Histologic examination is important to rule out incidental findings, such as perianal intraepithelial neoplasia, anal carcinoma, melanoma, or coexisting infections. Special attention should be given when patient is immunocompromised. We present a case of a 41-year-old man with a history of ulcerative colitis on adalimumab who presented with anal lesions. He was diagnosed with hemorrhoids and surgically treated. Microscopic examination confirmed the diagnosis of hemorrhoids. However, foci of epithelium with viral cytopathic effects were noted. A varicella zoster virus (VZV)-specific immunostain was positive in the areas of interest confirming the diagnosis of the VZV infection limited to the hemorrhoids. Combined herpes simplex virus type 1 and 2 (HSV 1 and HSV 2) immunostain was also performed and was negative. Anal herpes has been widely described in the literature, particularly in immunocompromised patients. However, isolated VZV infection in hemorrhoids to the best of our knowledge has never been reported., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: There is no consensus on the number of ligation bands for varying grades of internal hemorrhoids (IH) in a single session of endoscopic rubber band ligation (ERBL)., Aims: The aims of this study were to investigate this issue., Methods: Patients with IH were treated with ERBL. The primary endpoint was no hemorrhoid symptoms 6 weeks after ERBL. The secondary endpoints were postoperative complications and recurrence., Results: One hundred twenty-three eligible patients met the inclusion criteria, and 3 patients were excluded. The average bands were 3.9 ± 1.1, and grade II hemorrhoids required significantly fewer bands than grade III hemorrhoids (3.45 ± 0.85 vs 4.35 ± 1.06, P = 0.000). 78.8% of patients achieved the primary endpoint. The efficacy of grade II hemorrhoids was higher than that of grade III hemorrhoids (87.8% vs 69.2%). The incidence of postoperative complications was not significantly correlated with the grade of hemorrhoids (P = 0.201) and the number of bands (P = 0.886). The median follow-up time was 14.3 ± 7.9 (1.3-30.9) months. The overall recurrence rate was 25.0%, with grade III significantly higher than grade I-II (32.8% vs 14.6%, P = 0.027). For grade III hemorrhoids, the recurrence rate was lower with more than 4 bands of ligation than with less than 4 bands (26.5% vs 53.3%)., Conclusions: The average ERBL treatment of IH requires nearly four bands, and grade II hemorrhoids require less banding than grade III hemorrhoids, while the efficacy was better. Increasing the number of bands improves the treatment efficacy for grade III IH, which could be a strategy to reduce the recurrence rate without increasing postoperative complications., (© 2023. The Author(s), under exclusive licence to Royal Academy of Medicine in Ireland.)

Objectives: To evaluate the safety and efficacy of catheter-directed hemorrhoidal embolization (CDHE) by microcoil embolization for rectal bleeding due to hemorrhoids classified as Goligher grade I-III., Methods: Eighty patients (62.5% males) with a mean age of 48 ± 9 years were recruited prospectively. All patients had symptomatic bleeding hemorrhoids. All patients were classified according to Goligher classification: grade I (13.7%), grade II (71.1%), grade III (15%), and no grade IV were recruited in this study. In all cases, microcoils were used to embolize the superior rectal artery(SRA), and microspheres if recurrence of bleeding occurred. Follow-up evaluation (1, 3, 6, and 12 months) included clinical examination and anoscopy. A questionnaire was conducted to determine improvement regarding bleeding, quality of life before, and the degree of patient satisfaction of each participant., Results: Technical success was achieved in 100% of the cases. Fifty-five (68.7%) participants had the absence of rectal bleeding after 12 months of embolization. VAS and QL improved 4 points and 1.5 respectively after embolization. A total of 25/80 (31.3%) had a recurrence in rectal bleeding. Seventeen (21.3%) patients underwent a second embolization, and four patients (5%) were treated with open hemorrhoidectomy. No major complications were observed. Sixteen participants had minor complications. Subjective post-treatment symptom and QL surveys showed significant differences from the baseline survey. Likewise, the degree of satisfaction in the telephone survey at 12 months revealed a high degree of patient satisfaction (8.3±1.1)., Conclusions: The present study demonstrates that CDHE is a feasible, well-tolerated, ambulatory, anal sphincter-sparing procedure for the treatment of internal hemorrhoids., Clinical Relevance Statement: CDHE is a simple procedure, well tolerated and accepted by patients, that preserves the anal sphincter and presents few complications when metal devices or microspheres are used as embolic agents., Key Points: • The technical success rate of CDHE, defined as the closure of all the SRA in their distal segment, was achieved 100% of all patients. However, a second embolization treatment was required since 21.25% of the patients experienced rectal bleeding. • Overall, CDHE's safety profile is acceptable. After the procedure and 1 year of follow-up, no significant complications were observed. • Encouraging clinical outcomes have demonstrated CDHE in individuals with hemorrhoids and mild prolapse Goligher grades I-III with persistent rectal bleeding., (© 2023. The Author(s), under exclusive licence to European Society of Radiology.)

Hemorrhoids are a prevalent anorectal condition that affects a wide range of adult populations. The severity of this condition was graded using a validated hemorrhoidal grading system, specifically focusing on grade III and IV cases. This retrospective study aimed to compare the clinical efficacy of a standard Procedure for Prolapse and Hemorrhoids (PPH) with a combined Doppler-guided Hemorrhoidal Artery Ligation (DG-HAL) and a PPH approach in patients with severe hemorrhoids. Conducted from May 2021 to January 2023, the study included patients aged 18-65 with confirmed diagnosis of Grade III or Grade IV hemorrhoids. Patients with a history of anorectal surgery and significant comorbidities were excluded. The control group underwent standard PPH, whereas the observation group received DG-HAL followed by PPH. Clinical outcomes were measured using variables such as the operative duration, intraoperative blood loss, postoperative wound healing time, and length of hospital stay. Efficacy was evaluated using a hierarchical scale and a visual analog scale (VAS) for postoperative pain. The complication rates were also assessed. baseline characteristics were homogeneous between the 2 groups. The observation group demonstrated significantly faster postoperative wound healing and shorter hospital stay (P < .01). The overall therapeutic efficacy in the observation group was 90.0%, which was higher than that of the control group (75.0%; P = .025). The VAS pain scores were also significantly lower in the observation group (P = .002). A marked decrease in complication rates was observed in the observation group (3.3%) compared with that in the control group (17.9%) (P < .05). The combined DG-HAL and PPH surgical approach exhibited superior clinical efficacy in treating severe hemorrhoids. This technique offers high effectiveness, reduced postoperative VAS pain scores, and lower complication rates. The long-term efficacy requires further observation., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Despite the benefits attributed to the use of local anesthesia (LA) for open hemorrhoidectomy (OH) in developed countries, this technique is still not considered as the first line technique in low-income countries such as Uganda; therefore, we aimed at comparing the cost of OH under LA versus Saddle block among patients with 3rd or 4th degree hemorrhoids., Methods: This trial was conducted from December 2021 to May 2022 among patients with primary uncomplicated 3rd or 4th degree hemorrhoids. The operating time, and direct costs in (US$) including medical and non-medical were recorded. We analysed the cost in the two groups (local anesthesia versus saddle block) using SPSS version 23.0., Results: Findings of fifty-eight patients were analysed including 29 participants per group. There was a significant difference in operating time and cost among the two groups (p < 0.05). The mean operating time was 15.52 ± 5.34(SD) minutes versus 33.72 ± 11.54 min for OH under LA and SB respectively. The mean cost of OH under LA was 57.42 ± 8.90 US$ compared to 63.38 ± 12.77US$ in SB group., Conclusion: The use of local anesthesia for OH was found to have less operating time with high-cost effectiveness. Being affordable, local anesthesia can help to increase the turnover of patients who would otherwise wait for the availability of anesthesia provider. Policy makers should emphasize its applicability in low-income settings to help in the achievement of 2030 global surgery goals., Trial Registration: Pan African Clinical Trials Registry, PACTR202110667430356. Registered on 08/10/2021., (© 2023. The Author(s).)

Purpose: Pain and reduced quality of life (QoL) are major subjects of interest after surgery for hemorrhoids. The aim of this study was to find predictive parameters for postoperative pain and QoL after hemorrhoidectomy., Methods: This is a follow-up analysis of data derived from a multicenter randomized controlled trial including 770 patients, which examines the usefulness of tamponade after hemorrhoidectomy. Different pre-, intra-, and postoperative parameters were correlated with pain level assessed by NRS and QoL by the EuroQuol., Results: At univariate analysis, relevant (NRS > 5/10 pts.) early pain within 48 h after surgery was associated with young age (≤ 40 years, p = 0.0072), use of a tamponade (p < 0.0001), relevant preoperative pain (p = 0.0017), pudendal block (p < 0.0001), and duration of surgery (p = 0.0149). At multivariate analysis, not using a pudendal block (OR 2.64), younger age (OR 1.55), use of a tamponade (OR 1.70), and relevant preoperative pain (OR 1.56) were significantly associated with relevant early postoperative pain. Relevant pain on day 7 was significantly associated only with relevant early pain (OR 3.13, p < 0.001). QoL overall remained at the same level. However, n = 229 (33%) patients presented an improvement of QoL and n = 245 (36%) an aggravation. Improvement was associated with a reduction of pain levels after surgery (p < 0.0001) and analgesia with opioids (p < 0.0001)., Conclusion: Early relevant pain affects younger patients but can be prevented by avoiding tamponades and using a pudendal block. Relevant pain after 1 week is associated only with early pain. Relief in preexisting pain and opioids improve QoL., Trial Registration: DRKS00011590 12 April 2017., (© 2023. The Author(s).)

Purpose: The aim of this study was to evaluate the efficacy and safety of radiofrequency ablation (RFA) in the management of haemorrhoidal disease with 1 year's follow-up., Method: This prospective multicentre study assessed RFA (Rafaelo © ) in outpatients with grade II-III haemorrhoids. RFA was performed in the operating room under locoregional or general anaesthesia. Primary endpoint was the evolution of a quality-of-life score adapted to the haemorrhoid pathology (HEMO-FISS-QoL) 3 months after surgery. Secondary endpoints were evolution of symptoms (prolapsus, bleeding, pain, itching, anal discomfort), complications, postoperative pain and medical leave., Results: A total of 129 patients (69% men, median age 49 years) were operated on in 16 French centres. Median HEMO-FISS-QoL score dropped significantly from 17.4/100 to 0/100 (p < 0.0001) at 3 months. At 3 months, the rate of patients reporting bleeding (21% vs. 84%, p < 0.001), prolapse (34% vs. 91.3%, p < 0.001) and anal discomfort (0/10 vs. 5/10, p < 0.0001) decreased significantly. Median medical leave was 4 days [1-14]. Postoperative pain was 4/10, 1/10, 0/10 and 0/10 at weeks 1, 2, 3 and 4. Seven patients (5.4%) were reoperated on by haemorrhoidectomy for relapse, and three for complications. Reported complications were haemorrhage (3), dysuria (3), abscess (2), anal fissure (1), external haemorrhoidal thrombosis (10), pain requiring morphine (11). Degree of satisfaction was high (+ 5 at 3 months on a - 5/+ 5 scale)., Conclusion: RFA is associated with an improvement in quality of life and symptoms with a good safety profile. As expected for minimally invasive surgery, postoperative pain is minor with short medical leave., Clinical Trial Registration and Date: Clinical trial NCT04229784 (18/01/2020)., (© 2023. The Author(s).)

Objective: To compare transanal hemorrhoidal dearterialization (THD) with mucopexy to Ferguson hemorrhoidectomy in terms of recurrence rates and quality of life., Background: There is uncertainty regarding the durability of the therapeutic effect of THD with mucopexy compared with Ferguson hemorrhoidectomy in terms of recurrence rates., Methods: This was a multicenter prospective study. Participating surgeons performed the operation they knew best enrolling 10 patients each. Surgeons' unedited videos were reviewed by an independent expert. Patients with prolapsed internal hemorrhoids in at least 3 columns were eligible. The primary endpoint was recurrence rates defined as prolapsing internal hemorrhoids. Patient-reported outcomes and satisfaction were evaluated with Pain Scale and Brief Pain Inventory, Fecal Incontinence Quality Of Life (FIQOL), Cleveland Clinic Incontinence, Constipation, Short-Form 12 scores, and Patient satisfaction (4-point Likert) scale., Results: Twenty surgeons enrolled 197 patients. THD patients had lower Visual pain scores at postoperative day (POD) 1 (6.2 vs 8.3, P =0.047), POD7 (4.5 vs 7.7, P =0.021), POD14 (2.8 vs 5.3, P <0.001), and medication use at POD14 (23% vs 58%, P <0.001). Median follow-up was 3.1 (1.0-5.5) years. Recurrence rates did not differ between the study arms (5.9% vs 2.4%, P =0.253). Patient satisfaction rate was higher after THD at POD14 (76.4% vs 52.5%, P =0.031) and 3 months (95.1% vs 63.3%, P =0.029), but did not differ at 6 months (91.7% vs 88%, P =0.228) and 1 year (94.2% vs 88%, P =0.836)., Conclusion: THD with mucopexy was associated with improved patient-reported outcomes and quality of life as compared with Ferguson hemorrhoidectomy with nonsignificantly different recurrence rates., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction and Hypothesis: Rectovaginal fistula is an epithelium-lined direct communication route between the vagina and the rectum. The gold standard of fistula management is surgical treatment. Rectovaginal fistula after stapled transanal rectal resection (STARR) may be challenging to treat, due to the extensive scarring, the local ischemia, and the risk of rectal stenosis. We aimed to present a case of iatrogenic rectovaginal fistula after STARR that was successfully treated with a transvaginal primary layered repair and bowel diversion., Methods: A 38-year-old woman was referred to our division for continuous fecal discharge through her vagina that developed a few days after she had a STARR for prolapsed hemorrhoids. Clinical examination revealed a 2.5 cm-wide direct communication between the vagina and rectum. After proper counseling, the patient was admitted to transvaginal layered repair and temporary laparoscopic bowel diversion RESULTS: No surgical complications were observed. The patient was successfully discharged home on postoperative day 3. Bowel diversion was reversed after 2 months. At the current follow-up (6 months), the patient is asymptomatic and without recurrence., Conclusions: The procedure was successful in obtaining anatomical repair and relieving symptoms. This approach represents a valid procedure for the surgical management of this severe condition., (© 2023. The International Urogynecological Association.)

Background: 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., Methods: 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 1 st week, 1 st , 3 rd and 6 th months. Surgical success was assessed at 1 month. Hemorrhoidal Disease Symptom Score (HDSS) and Short Health Scale (SHS) were applied at baseline and the 6 th month. Wexner fecal incontinence score was applied at all follow-up studies., Results: 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., Conclusion: 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., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Aim: Laser haemorrhoidoplasty (LHP) is an emerging nonexcisional surgical procedure in which the arteriovenous flow of the haemorrhoidal plexus is interrupted through laser coagulation. The aim of this cohort study was to assess efficacy of LHP in treating symptomatic haemorrhoidal disease through patient satisfaction, remission of symptoms (blood loss, pain, itching, soiling, mucosal prolapse) and recurrence of haemorrhoids., Methods: Patients who underwent treatment for symptomatic haemorrhoids (degrees 1-4) through an LHP procedure between 2015 and 2021 were included in the study. A 1470 nm-diode laser was used. A total of 200 patients (71% male, average age 51 years) were analysed. Primary outcomes were patient satisfaction and/or complete recovery of symptoms. Secondary outcomes were operating time, complications and recurrence rates. Patient satisfaction, postoperative blood loss, pain and complications were evaluated 6-7 weeks postoperatively. Room turnover time and operating time were documented. Recurrence of haemorrhoids following LHP treatment within 1 year was evaluated., Results: Patient satisfaction regarding LHP treatment was reached in 155 (84,7%) patients. Postoperative blood loss was reported by 44 (24,0%) patients during time of evaluation. Twenty-four (13,1%) patients reported postoperative pain after 6-7 weeks. Postoperative complications occurred in seven patients (3 anal fissures, 2 perianal abscess, 1 perianal fistula, 1 postoperative anaemia). Room turnover time (patient in to patient out) was 21 min with an average operating time of 7 min. Recurrence of haemorrhoids within 1 year occurred in 50 (27,3%) patients., Conclusions: Laser haemorrhoidoplasty appears to be a promising and effective nonexcisional surgical procedure in the treatment of symptomatic haemorrhoidal disease with high patient satisfaction, acceptable postoperative symptoms, minimal complications and short operating times., (© 2023 Association of Coloproctology of Great Britain and Ireland.)

Background and Study Aims: Outlet obstructive constipation (OOC) is a common type of chronic constipation that is usually caused by internal hemorrhoids (IH) and rectal mucosal prolapse (RMP). Cap-assisted endoscopic sclerotherapy (CAES) was demonstrated to be effective in the treatment of IH and RMP. This study explored the efficacy of CAES in treating OOC associated with IH and RMP., Methods: Thirty-one patients (15 males and 16 females) were diagnosed with OOC after colonoscopy and anorectal manometry (AM). CAES was used to treat IH and RMP. The self-rating anxiety scale (SAS), self-rating depression scale (SDS), and Wexner constipation score (WCS) were used to assess patients at baseline and at the end of follow-up. AM tests were performed before and after CAES., Results: The mean age of patients was 56.19 ± 7.969 years, and the follow-up time was 2.875 ± 3.703 months. After CAES treatment, subjective indices, including frequency of bowel movements (p < 0.05), defecation time (p < 0.05), SAS (p < 0.05), SDS (p < 0.05), and WCS (p < 0.05), were significantly improved. AM showed that the anal relaxation rate (p < 0.05), maximum squeeze pressure (p < 0.05), and rectal residual pressure (p < 0.05) were significantly improved. The ratio of Bristol stool form scale typeIII-Vincreased from 12.5 % to 56.25 % (p < 0.05)., Conclusions: CAES is effective for treating OOC caused by IH and RMP. The relief of OOC symptoms could improve anxiety and depression symptoms associated with the disease., Competing Interests: Declaration of competing interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.)

Purpose: The purpose of this study was to explore the effect of electroacupuncture (EA) at Baliao point on short-term complications, such as anal pain and swelling, after procedure for prolapse and hemorrhoids (PPH) in patients with mixed hemorrhoids., Methods: A total of 124 eligible patients undergoing PPH surgery were included in this study and randomly divided into a control group (n = 67) and an EA group (n = 57), with patients in the control group receiving only PPH surgery and patients in the EA group receiving PPH surgery and EA at Baliao point., Results: The visual analogue scale (VAS) scores of EA group at 8, 24, 48, and 72 h after operation were significantly lower than those of control group. The anal distension scores at 8, 48, and 72 h after operation were also significantly lower than those of control group. The number of postoperative analgesic drug administration per patient was also significantly lower in the EA group. The incidence of urinary retention and tenesmus in EA group was significantly lower than that in control group within the first day after surgery., Conclusion: EA treatment at the Baliao point can alleviate short-term anal pain and anal swelling after the procedure for prolapse and hemorrhoids, reduce the incidence of urinary retention, and decrease the use of postoperative analgesic drugs., Trial Registration: This study was approved and registered by the Chinese Clinical Trial Center, Registration number: ChiCTR2100043519, Registration time: February 21, 2021 ( https://www.chictr.org.cn/ )., (© 2023. The Author(s).)

This article provides a practice-oriented overview of the most common proctological diseases: Anal eczema, hemorrhoidal disease, anal thrombosis, marisca, anal abscess and fistula, and anal fissure. Definitions and etiopathogenesis, clinic and diagnostics, and current therapy are presented., Competing Interests: Erklärung zu finanziellen InteressenForschungsförderung erhalten: nein; Honorar/geldwerten Vorteil für Referententätigkeit erhalten: nein; Bezahlter Berater/interner Schulungsreferent/Gehaltsempfänger: nein; Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an Firma (Sponsor der Veranstaltung): nein; Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an Firma (Nicht-Sponsor der Veranstaltung): nein.Erklärung zu nichtfinanziellen InteressenDie Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Hemorrhoidal disease is a common and troublesome condition. Excisional hemorrhoidectomy can assure the best chance of cure but it is hampered by postoperative pain and potential long-term morbidity therefore minimally invasive techniques have been developed. Since 2009 a doppler-guided hemorrhoidal dearterialization with laser (the hemorrhoidal laser procedure; HeLP) has been proposed to control symptoms without significant sequelae. The aim of this systematic review is to analyze the benefits and disadvantages of HeLP for symptomatic hemorrhoids. The Medline/PubMed, Embase, and Cochrane library databases were searched from January 2010 to March 2022, language was restricted to English and documents to the full text. Randomized and non-randomized, prospective and retrospective cohort studies were included. Risk of bias assessment was performed using the Risk of bias for non-randomized studies (ROBINS-I) and the RoB2 Tool for randomized clinical trial. Primary outcome was to assess the efficacy of HeLP on symptoms' resolution. Secondary objectives were postoperative pain and complications, comparison with other interventional techniques, and evaluation of long-term recurrence. Whenever possible, a meta-analysis was conducted. The GRADE approach was employed to assess the certainty of evidence. We included six non-randomized and one randomized study. HeLP improved or resolved preoperative symptoms in 83.6 to 100% of patients during follow-up. In the randomized study symptoms resolved in 90% of patients after HeLP and 53.3% after rubber band ligation as comparator. Published data indicate that HeLP is effective, relatively safe, with limited recurrence rate, after a short to medium follow-up. The quality of evidence was however low. There is a paucity of studies assessing the benefits or harms of laser dearterialization for the treatment of hemorrhoids and randomized trials are furthermore rare, therefore trials with adequate power and proper design, assessing the advantages and disadvantages of HeLP versus other minimally invasive techniques, are needed. Furthermore, studies evaluating long-term follow-up are wanted., (© 2023. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Introduction: Lower Gastro intestinal bleeding (LGIB) is one of the most important clinical symptoms which have significant morbidity and mortality. It has an annual admission rate of 0.15% with mortality rate of 5-10%. LGIB can be caused by number of causes which includes both neoplastic and non-neoplastic lesions. Colonoscopy is the gold standard diagnostic measure which is simple, convenient and cost effective procedure. The present study was aimed to assess the Colonoscopic profile of LGIB presenting to our tertiary care centre in south India. The study was conducted for 6 months period., Materials: This is a hospital based study cross-sectional observational study conducted in a tertiary health care centre. A total number of 58 adult subjects with LGIB aged above 18 years were recruited in this study and History, clinical examination, blood tests were taken., Result: In our study among the 58 subjects, 33 were male. Majority of our patients were between the mean age of 31-40 years. Most colonoscopic findings were suggestive of ulcerative colitis which equalled to 31%. Other different aetiologies of LGIB were as following: CA colon (15%), haemorrhoids (15%), colonic polyps (14%) CA anal canal (5%) and so on. Majority of our patients had moderate anaemia which was equal to 45%, due to persistent LGIB., Conclusion: The incidence of lower GI bleeding increased with increasing age among our patients. The leading cause of lower GI bleeding was found to be ulcerative colitis. It was followed by CA colon, haemorrhoids and colonic polyps hence colonoscopy is recommended in all patients chronic LGIB. References Hilsden RJ, Shaffer EA. Management of gastrointestinal hemorrhage. Can Fam Physician 1995;41:1931-6, 1939-41. Sahn B, Bitton S. Lower gastrointestinal bleeding in children. Gastrointest Endosc Clin NA 2016;26(1):75-98., (© Journal of the Association of Physicians of India 2011.)

The purpose of this case report is to evaluate and demonstrate the benefits of compounded therapy in treating chronic rectal fissures with hemorrhoids using a compounded suppository containing cromolyn sodium and naltrexone hydrochloride in MEDISCA's SPG SUPPOSI-BASE. The primary outcomes of symptomatic improvement and healed fissure were reported and confirmed by the practitioner and, via self-assessment, by the patient, which was observed after a long-troubled history of failed treatments. The case had no side effects or complications, and the patient reported a full recovery after using this compounded therapy for ten days., (Copyright© by International Journal of Pharmaceutical Compounding, Inc.)

Case Summary: A 48-year-old healthy man presented to the office reporting a long-standing history of anal pruritus. He had tried various over-the-counter creams without much success. Besides an anal fissure in the past, which responded to nitroglycerin ointment, his medical history was unremarkable. On physical examination, he was found to have grade I hemorrhoids and mild fecal smearing on perianal skin. Recent colonoscopy and laboratory work ordered by the primary care provider were normal. He was counseled on common inciting agents and local irritants and was advised on hygiene, diet modification, and stool-bulking agents. The colorectal surgeon recommended that the patient keep a journal about his symptoms, foods, and household chemicals used. He was seen twice more over the course of 6 months to pinpoint the cause of his pruritus. A short-course trial of topical steroid, barrier cream, and topical tacrolimus was not helpful. A biopsy of perianal skin was performed and was unrevealing. Eventually, given the persistence of symptoms, it was decided that he would undergo methylene blue injection to address his pruritus (Fig. 1). The procedure consisted of several intradermal and subcutaneous injections of 10 mL of 1% methylene blue combined with 7.5 mL of 0.25% bupivacaine with adrenaline (1/100,000) and 7.5 mL 0.5% lidocaine. After the methylene blue injection, the severity of his symptoms improved, but pruritus still persisted. A methylene blue injection of the same concentration was repeated in 3 months with complete resolution of symptoms., (Copyright © The ASCRS 2022.)

Introduction: Minimally invasive techniques still continue to maintain their popularity in hemorrhoidal disease. In this study, we aimed to present the symptomatic recovery and recurrence rates, post-operative pain levels, and complication rates of patients treated with the laser hemorrhoidoplasty (LHP) method in our clinic., Methods: The data of patients who underwent LHP due to Grades 2, 3, and 4 internal hemorrhoidal disease in our clinic were reviewed retrospectively. The patients enrolled in the study were followed for at least 6 months (6 months, 1 year, and 2 years) and their results were analyzed., Results: A total of 103 patients were included in the study. Seventy-five (72.8%) of them were male and the mean age was 41.6 ± 13.6 years. The mean operation time was 17.9 ± 5.2 min and minor complications developed in 3 (2.9%) patients postoperatively. Mean time to return to normal daily life was 2.17 (1-11) days. Recurrence developed in 16 (17.6%) patients with Grades 2 and 3 disease and in 6 (50%) of 12 patients with Grade 4 disease (p = 0.019)., Conclusion: LHP is a popular procedure which is effective in selected patient groups with acceptable recurrence rates., (Copyright: © 2023 Permanyer.)

Objective: To compare the efficiency and safety of laser haemorrhoidoplasty (LH) with Ferguson haemorrhoidectomy (FH) in patients with third- and fourth-grade haemorrhoids., Study Design: Randomised controlled trial., Place and Duration of Study: General Surgery Clinic, Medipol University Pendik Hospital, İstanbul, Turkey, from 1st December 2021 to 1st May 2022., Methodology: The patients who had an indication for surgery for grade III or grade IV haemorrhoidal disease (HD) and who were 18 years and older were randomly allocated to the two study groups. While LH was performed using a 980-diode laser in the patients enrolled in the laser group, a standard FH was performed using diathermy in the patients in the second study group. The length of surgery (LOS), the number of excised lumps, wound healing time, time to symptom relief, pre- and postoperative Visual Analogue Scale (VAS) scores and the difference between them (Δ VAS), and complication rates were compared between two study groups., Results: LH had less LOS with a similar number of excised lumps, furthermore, it provided faster-wound healing and less time-to-symptom relief when compared to FH. The median VAS score decreased from 5 to 0 in the LH group and from 5 to 2 in FH, and Δ VAS scores of the groups were statistically significantly different (p<0.001). LH also had better outcomes than FH in terms of having any type of postoperative complication., Conclusion: LH might be an alternative treatment modality in patients with grade III and grade IV HD with a low level of complication rate., Key Words: Haemorrhoids, Laser therapy, Haemorrhoidectomy, Operative time, Pain measurement, Postoperative complications.

Lower gastrointestinal bleeding (LGIB), originating mainly in the colon, rectum and anus, occurs most often in older patients (7th decade) with co-morbidity, half of whom have coagulation abnormalities due to anti-coagulant or anti-aggregant therapy. In three cases out of four, bleeding regresses spontaneously but can recur in up to one third of patients. The main causes are diverticular disease, vascular disorders (hemorrhoids, angiodysplasia) and colitis. Ten to 15% of patients present in hypovolemic shock. The main problem is to determine the precise location and etiology of bleeding. First-line steps include correction of hemodynamics, correction of coagulation disorders and transfusion, as necessary. Rectal digital examination allows differentiation between melena and hematochezia. In patients with severe LGIB, upper endoscopy can eliminate upper gastro-intestinal bleeding (UGIB). Computerized tomography (CT) angiography can pinpoint the source. If contrast material extravasates, the therapeutic strategy depends on the cause of bleeding and the general status of the patient: therapeutic colonoscopy, arterial embolization and/or surgery. In the absence of severity criteria (Oakland score≤10), ambulatory colonoscopy should be performed within 14 days. Discontinuation of anticoagulant and/or antiplatet therapy should be discussed case by case according to the original indications., (Copyright © 2022. Published by Elsevier Masson SAS.)

Background: Hemorrhoidal disease (HD) is one of the most common anorectal benign disorder affecting millions of people around the world. Grade I-II HD are generally treated with a conservative approach with topical products such as creams and ointments considered a safe and effective option to treat mild symptoms. The aim of the present study was to assess the safety and efficacy of a topical medical device (Lenoid ™ ; International Health Science [IHS] - Biofarma Group, Mereto di Tomba, Udine, Italy) in patients affected by symptomatic HD., Methods: This study is a randomized, double blind, placebo-controlled, 2-weeks clinical trial. Patients affected by I-II grade symptomatic HD were enrolled in the study and then randomly assigned to Lenoid ™ arm (LA) or placebo arm (PA), respectively. Patients were evaluated before and after intervention through clinical examination and disease-specific questionnaires assessing symptoms such as pain, tenesmus, pruritus and anal discharge., Results: A total of 68 patients were screened and 60 (30 in each group) were enrolled into the study. All patients belonging to LA showed a statistically significant improvement of each symptom after 7 and 14 days of treatment when compared to PA (P<0.001). Furthermore, subjective improvement of change in overall assessment of disease was observed in the LA but not in the PA. No serious adverse events were recorded., Conclusions: The tested product was found safe and effective in improving clinical signs and symptoms in patients with grade I-II HD.

Introduction and Hypothesis: The objective was to investigate the symptom prevalence of anorectal dysfunction (AD) in women with pelvic organ prolapse (POP) and whether symptom improvement can be achieved by pelvic floor surgery., Methods: Secondary analysis of the Propel Study data from 277 women with POP stage II-IV regarding bothersome AD symptoms, which were assessed using the Pelvic Floor Distress Inventory (PFDI) questionnaire preoperatively, and 6, 12, and 24 months after transvaginal prolapse repair with Elevate anterior and posterior., Results: Prevalence of AD was high in the study cohort (14.4-56.3%) and could be reduced significantly throughout a 2-year follow-up (cure rates 44.3-83.1%). AD symptoms decreased in a similar manner after posterior/apical fixation to the way they did after anterior/apical fixation (e.g., feeling of incomplete bowel emptying 66.7% to 25.5% vs 46.5% to 10.7% respectively). Hemorrhoids and loss of loose stool decreased even more after anterior/apical fixation than after posterior/apical fixation. Even though AD symptoms decreased significantly more in patients with POP stage III-IV, there was still a considerable improvement in patients with POP stage II (e.g., pain when passing stool 31.1 to 7.7% vs 21.4 to 0% respectively). Notably, even symptoms of hemorrhoids and rectal prolapse improved substantially (cure rates 44.2% and 70.1% respectively)., Conclusions: Symptoms of AD were frequent in our study cohort, and they significantly improved after vaginal mesh-augmented sacrospinous prolapse repair with Elevate anterior and posterior throughout the follow-up period. Anterior/apical fixation showed results that were almost as good as those after posterior/apical fixation. Patients with POP stage II experienced considerable symptom improvement, but cure rates were significantly higher in patients with POP stage III-IV. Vaginal mesh-augmented prolapse repair with good apical fixation is efficacious in resolving AD symptoms with low de novo rates in women suffering of POP., (© 2022. The International Urogynecological Association.)

Chronic hemorrhoidal disease is a common anorectal condition that leads to hemorrhoidal hyperplasia, which affects millions of people worldwide and is a significant medical and socioeconomic issue. Rectal bleeding is one of the main chronic symptoms. Recurrent rectal bleeding can alter an individual's quality of life and, more rarely, cause anemia. Pain is less common, occurring only in the event of complications such as congestive exacerbation, external hemorrhoidal thrombosis, or fissures. The most standard treatment involves dietary and hygiene measures, use of phlebotonic drugs, and nonsurgical treatment such as infrared photocoagulation or elastic band ligation. Excisional treatments such as hemorrhoidectomy and hemorrhoidopexy are the reference standards for treatment of hemorrhoidal disease. Embolization of the rectal arteries (ie, emborrhoid) has recently emerged as an effective treatment option, with few reported adverse effects, minimal blood loss, and a same-day hospital procedure. Hemorrhoid embolization is performed by using femoral or radial access. The inferior mesenteric artery and then the superior rectal arteries are catheterized with a microcatheter. Embolization can be performed by using different agents. Studies have shown improvement in symptoms and high technical success rates after treatment. The basic principles of hemorrhoid embolization that must be understood to achieve effective treatment, including those related to patient evaluation, the arterial anatomy, basic embolization, and published results, are reviewed. An invited commentary by Thompson and Kelley is available online. © RSNA, 2022.

Competing Interests: L’auteur déclare n’avoir aucun lien d'intérêts.

Surgery for benign anal conditions is a common practice and is usually followed by a good outcome. The present review aimed to summarize the emergence and evolution of different laser techniques used for the treatment of benign anal conditions and report their current outcome. PubMed and Scopus were searched for studies that assessed the use of laser in benign anal conditions. Anal conditions reviewed were hemorrhoids, anal fistula, anal warts, anal stenosis, and anal fissure. The full text of the studies retrieved was summarized in a narrative and tabular form. Laser techniques used for the treatment of hemorrhoidal disease were laser open hemorrhoidectomy, laser hemorrhoidoplasty, and Doppler-guided hemorrhoidal laser dearterialization. Resolution of hemorrhoidal symptoms was reported in 72-100% of patients after laser treatment. YAG laser, fistula laser closure, and photodynamic therapy have been used for the treatment of anal fistula with success rates ranging from 20 to 92.6%. Anal warts can be treated with photodynamic therapy with or without YAG or CO 2 laser with a success rate up to 88%. A few studies reported the use of laser in the treatment of chronic anal fissure and anal stenosis. The use of laser in the treatment of benign anal conditions is associated with promising outcomes. Laser was most assessed in hemorrhoidal disease and anal fistula and showed more consistent success rates with hemorrhoidal disease than with anal fistula. Preliminary reports assessed the outcome of laser treatment in other conditions as anal fissure and warts with acceptable outcomes., (© 2022. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Background: Hemorrhoids, a common anorectal disease, seriously affects patients' quality of life. Micronized purified flavonoid fractions (MPFF) have been shown to improve hemorrhoid symptoms., Purpose: To evaluate the efficacy and safety of MPFF in treating postoperative hemorrhoid complications., Study Design: A systematic review and meta-analysis of existing literature on natural compounds for treating postoperative complications of hemorrhoids., Methods: A literature search was conducted using five databases, namely PubMed, WanFang, CNKI, Embase, and the Cochrane Library, to identify randomized controlled trials (RCTs) on the effects of MPFF treatment on hemorrhoids. Stata 15.1 and Revman 15.4 were used to assess the data, while subgroup and sensitivity analyses were performed to evaluate potential heterogeneity, and trial sequential analysis (TSA) and Egger test were used to evaluate the reliability of each trial., Results: A total of 22 RCTs, including 2,335 participants were included in the analysis. MPFF improved the clinical efficacy of post-hemorrhoidectomy and reduced the bleeding rate, pain score, and edema score, although no substantial effect on adverse reactions was reported. Subgroup analyses showed a significant reduction in pain score and bleeding rate in trials with duration of 4-10 days and an improvement in clinical efficacy. Treatment for ≥ 10 days significantly improved the edema score; a dosage range of 1,800-2,700 mg/day of MPFF significantly reduced edema and pain scores, whereas < 1,800 mg/day significantly improved clinical efficacy., Conclusions: Based on searching the relevant literatures, this is the first meta-analysis on MPFF treatment of postoperative hemorrhoid complications. Our findings, validated by TSA, suggest that MPFF is safe and effective in reducing postoperative hemorrhoid complications, and that dose and duration are key factors in its efficacy, as illustrated by subgroup analysis. However, due to the small sample size, the standardized treatment regimen of MPFF could not be obtained; therefore, further research is warranted., (Copyright © 2022 Elsevier GmbH. All rights reserved.)

Background: The management of hemorrhoidal disease (HD) in patients with bleeding disorders (BD) is challenging. Polidocanol foam sclerotherapy (PFS) is associated with a low rate of bleeding complications. The aim of this study was to compare the efficacy and safety of PFS in the treatment of HD in patients with and without BD., Methods: This prospective, multicenter, cohort study enrolled patients with (group B) and without (group A) BD, with symptomatic internal HD grades I-III over an 18-month period. All patients were treated with PFS. Patients with congenital BD did not undergo prior replacement therapy and those with acquired BD due to antithrombotic drugs, did not discontinue therapy. Efficacy outcomes included therapeutic success and HD recurrence during a 1-year follow-up period. To evaluate safety the complications related to PFS were recorded., Results: We included 228 patients (group A: 155, group B: 73; male/female: 114/114; mean age: 59.4 ± 15.9 years). The baseline hemorrhoidal disease bleeding grade (p < 0.001) and Sodergren hemorrhoidal symptom severity score (p = 0.019) were higher for group B. The overall therapeutic success rate was 93.4% with an average number of sessions of 1.51 ± 0.74, significantly higher for group B (1.68 ± 0.86 vs 1.43 ± 0.65, p = 0.013). Complications occurred in 11.4% of the patients, with bleeding reported in 4.8%. The majority of complications were mild (96.2%). No significant differences between the two groups were observed for therapeutic success, recurrence, or complication rate., Conclusions: Patients with BD may have more symptomatic HD at baseline. Even so, PSF showed similar effectiveness and safety in patients with BD compared to patients without BD., (© 2022. Springer Nature Switzerland AG.)

Hemorrhoids are common anorectal pathology, with high recurrence rates after surgical treatment. It is hypothesized that high straining forces during paradoxical contractions and inadequate relaxation are causally related to hemorrhoids. This review aimed to assess the coprevalence of functional constipation and dyssynergic defecation in a population with hemorrhoids. Moreover, the effects of rubber band ligation (RBL) were analyzed. Sources included Pubmed, Embase and CENTRAL . Randomized trials, cohort and case-control studies that investigated the prevalence of constipation in patients with hemorrhoids or the prevalence of hemorrhoids in patients with constipation compared to healthy subjects were included. Manometric studies were also eligible. Quality assessment was performed by using the Newcastle Ottawa Quality Assessment Scale. The primary outcome was the prevalence of functional constipation or dyssynergic defecation in patients with hemorrhoids. Nineteen studies were included. Prevalence of constipation was significantly higher in patients with hemorrhoids compared to controls [OR (odds ratio), 2.09; 95% CI (confidence interval), 1.27-3.44]. No significant difference in the prevalence of hemorrhoids between patients with constipation compared to controls was found (OR, 2.37; 95% CI, 0.67-8.44). Anal pressures in patients with hemorrhoids were significantly higher compared to healthy controls in all manometric studies. After RBL, these pressures remained significantly higher in patients with hemorrhoids ( P  = 0.001). Functional constipation, dyssynergic defecation and higher basal anal pressures are more prevalent in patients with hemorrhoids compared to controls. Improvement of therapy for functional constipation, especially dyssynergic defecation patterns, might lead to better long-term outcomes and reduce recurrence., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Haemorrhoidal disease (HD) plagues one in every ten people, with a plethora of surgical treatment modalities, of which laser haemorrhoidoplasty (LHP) is a relatively novel option. This systematic review and meta-analysis objectively evaluated the efficacy, safety, and tolerability of LHP compared against conventional (Milligan-Morgan) open haemorrhoidectomy (CoH)., Method: A comprehensive search of MEDLINE, EMBASE, CENTRAL, and Google Scholar was conducted. Randomised controlled trials (RCTs) and comparative cohort studies (CCSs) which compared LHP against CoH were included, with postoperative pain as the primary outcome. Secondary outcomes included intraoperative characteristics, short- and moderate-term outcome, and complications., Results: A total of 12 studies (6 RCTs and 6 CCSs), with a total of 1824 patients, were analysed. LHP resulted in reduced postoperative pain for the first day (mean difference of 2.07 visual analogue scale units), week, and month. The mean dosage and duration of postoperative analgesia use was similarly lower, with a mean difference of 4.88 mg (morphine) and 2.25 days, respectively. Crucially, recurrence was equivocal (HR: 0.72, CI: 0.21-2.40) at a mean follow-up duration of 8.58 ± 9.55 months. LHP resulted in lower blood loss and was 12.74 min shorter on average. LHP's postoperative recovery time was 9.03 days less with equivalent or decreased risk of most short- and moderate-term complications except anal thrombosis., Conclusion: Our study suggests that LHP is more tolerable than CoH, providing patients with superior postoperative quality of life at equivalent moderate-term efficacy. These findings contribute to improved understanding of LHP and its potential at enhancing the quality of HD care., (© 2022. The Author(s).)

Background: Hemorrhoidal disease is characterized by painless rectal bleeding and palpable swelling in the anus and very common in the society. In the presence of pain, it is called a complicated hemorrhoidal disease including conditions, such as thrombosed hemorrhoids, strangulation of the internal hemorrhoid, or accompanying anal fissure. Edema that develops as a result of impaired venous return is accepted as the main source of pathology in the development of strangulated internal hemorrhoidal disease, which is one of these complicated conditions., Case Presentation: This case report shows that strangulated hemorrhoidal disease can also develop due to a mechanical cause as a result of incarceration of the hemorrhoid into the accompanying perianal fistula tract., Key Words: Anorectal pain, Hemorrhoidal disease, Strangulated internal hemorrhoidal, Perianal fistula.

Background: The aim of this study was to evaluate the safety and efficacy of radiofrequency ablation (RFA) for treating third degree haemorrhoids, with a follow-up over 2 years., Methods: We conducted a prospective, two-centre study to assess RFA of third-degree haemorrhoids in an outpatient setting. Treatment was performed under local anaesthesia, optionally in combination with sedation. The primary endpoint was analysis of a proctological symptom score ([PSS] bleeding, itching, pain, soiling) and proctological examination to detect recurrence at 1, 6, 12 and 24 months after surgery. The secondary endpoints were postoperative complications, incidence of postoperative pain, including administration of analgesics and time to return to daily routine., Results: Ninety-eight patients were included in the study. The mean age of the patients was 49.1 ± 10.9 (mean ± SD). 83 patients (84.7%) were male and 15 patients (15.3%) were female. The follow-up involved 100% (1 month), 95% (6 months), 86% (12 months) and 74% after 24 months. The individual symptom scores and overall PSS score decreased significantly in comparison to the initial score at each time point assessed. Prolapsed haemorrhoids decreased in comparison to the initial situation (100%) to 7.2% (1 month), 3.5% (6 months), 13.1% (12 months) and 13.7% (after 24 months). Thirteen patients (12.7%) required repeat haemorrhoid therapy during the 2-year follow-up period. The mean maximum pain score after the procedure was 2.5 ± 2.7 (determined with the visual analogue scale), while 33 (33.7%) patients reported having no pain. 59 (60.2%) patients did not take analgesics after the procedure. Eleven patients (11.2%) experienced minor complications (bleeding, fever, cramps, diarrhoea, anal venous thrombosis) but did not require additional treatment. Eight cases (8.2%) of major complications (infection, bleeding, severe pain) required treatment with antibiotics, a second intervention, analgesics or hospitalization., Conclusions: RFA is safe and effective for treatment of third-degree haemorrhoids. The main advantages of this new method are its use on an outpatient basis under local anaesthesia, a very low level of postoperative pain and significant control of haemorrhoid symptoms over 2 years., (© 2022. The Author(s).)

Aim: There is little evidence for the best therapy for perianal thrombosis. No prospective trials exist. Even quality of retrospective data is low, due to low patient numbers or vague follow-up data., Patients and Methods: Six hundred nineteen patients with thrombosis of internal or external hemorrhoids who presented in our clinic between March 2017 and August 2018 were enrolled in the study. All patients were treated conservatively, with sitz baths and oral pain medication, if needed. No surgery was performed. Follow-up data was obtained by personal examination. Data was gathered prospectively, and data analysis was retrospective., Results: Five hundred four patients had perianal thrombosis (81.4%), and 115 patients had thrombosed hemorrhoids. Mean pain on a numerical rating scale (0-10) was 3.8 for perianal thrombosis and 5.2 for thrombosed hemorrhoids. Five hundred forty-eight patients (88.5%) did not need a sick leave. On follow-up, patients stated that their pain had largely resolved after 5 days and completely disappeared after 10 days. Local recurrence rate after perianal thrombosis was 6.3%., Conclusion: Perianal thrombosis and thrombosed hemorrhoids heal well without surgery. There is no evidence for advantages surgical therapy could offer., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Abstract: To investigate the clinical effect and outcome of traditional hemorrhoidectomy and procedures for prolapse and hemorrhoid (PPH) for the treatment of grades III and IV hemorrhoids.We retrospectively reviewed 1003 grades III and IV hemorrhoid patients who presented to our hospital. A total of 585 patients underwent PPH, and 418 patients underwent hemorrhoidectomy. The outcomes were 1-year recurrence, postoperative complications, surgery-related complications, and indicators.No significant difference between the 2 treatment groups regarding patient demographics. All patients underwent more than 12months of postoperative follow-up. No significant difference between the 2 treatment groups in 1-year recurrence. PPH can markedly improve anal pain, postoperative bleeding, difficult urination, and postoperative resting anal pressure. The operative blood loss, operative time, wound healing time, and wound infection rates were decreased significantly in the PPH group compared with the traditional hemorrhoidectomy group.Our data suggest that PPH is useful and safe for grades III and IV hemorrhoids. It can reduce postoperative and surgery-related complications. However, this was a single-hospital retrospective study. Therefore, well-designed, multicenter, randomized controlled trials are needed to evaluate the value of PPH for grades III and IV hemorrhoids., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

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

Anal stenosis, which develops as a result of aggressive excisional hemorrhoidectomy, especially with the stoutly use of advanced technologies (LigaSure ® , ultrasonic dissector, laser, etc.), has become common, causing significant deterioration in the patient's quality of life. Although non-surgical treatment is effective for mild anal stenosis, surgical reconstruction is unavoidable for moderate to severe anal stenosis that causes distressing, severe anal pain, and inability to defecate. The problem in anal stenosis, unlike anal fissure, is that the skin does not stretch as a result of chronic fibrosis due to surgery. Therefore, the application of lateral internal sphincterotomy does not provide satisfactory results in the treatment of anal stenosis. Surgical treatment methods are based on the use of flaps of different shapes and sizes to reconstruct the anal caliber and flexibility. This article aims to summarize most-used surgical techniques for anal stenosis regarding functional and surgical outcomes.

Background: Hemorrhoids are a widespread disease. Treatment options range from dietary measures to open surgery. A novel treatment approach is the embolization of the hemorrhoidal arteries., Method: A review was performed based on a selective literature search in PubMed representing the current state of research. The keywords "hemorrhoid" and "embolization" and "emborrhoid" were used. In addition, technical details of the hemorrhoidal embolization procedure are explained., Results and Conclusion: Embolization of hemorrhoidal arteries is a safe treatment, which allows efficient symptom control even in patients with contraindications for open surgery., Key Points: · Embolization of hemorrhoidal arteries is a new approach to the treatment of hemorrhoids.. · Embolization of hemorrhoidal arteries is feasible in patients with contraindications for open surgery such as hypercoaguable states and contraindications for general anesthesia.. · The endovascular approach causes no rectal and anal trauma and associated complications can be avoided.. · The treatment of bleeding hemorrhoids seems to be particularly effective.. · No ischemic complications have been reported so far when coils as well as particles were used.., Citation Format: · Feyen L, Freyhardt P, Schott P et al. Hämorrhoidenembolisation: Eine neue minimalinvasive endovaskuläre Therapieoption bei Hämorrhoidalleiden. Fortschr Röntgenstr 2022; 194: 266 - 271., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

In this work, we used photodynamic therapy(ALA-PDT) to treat 2 patients with perianal hemorrhoids combined with condyloma acuminatum. After 4 photodynamic treatments, the condyloma acuminata skin lesions completely disappeared. At the same time, we unexpectedly found that the patient's hemorrhoids skin lesions had mostly faded, and did not reappear during the half-year follow-up. Photodynamic therapy is satisfactory in the treatment of hemorrhoids combined with condyloma acuminatum, and the recurrence rate is low. We also have found that photodynamic therapy is equally effective on hemorrhoid skin lesions. PDT may be adopted as a new strategy in the study and treatment of hemorrhoids. To the best of our knowledge, no such cases have been reported., (Copyright © 2021. Published by Elsevier B.V.)

Painful and bothersome anorectal syndromes can be a diagnostic and therapeutic challenge for clinicians because structural and functional abnormalities may often coexist and require a multidisciplinary approach to management. Although it is often difficult to attribute all of a patient's anorectal symptoms to a singular disorder with definitive intervention and cure, improving quality of life, treating coexistent conditions such as functional constipation and/or defecation disorders, addressing psychological comorbidities if present, and confirming there is no evidence of inflammatory or malignant conditions are top priorities., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Postoperative pain is a major adverse effect of surgery for mixed hemorrhoids. We evaluated whether spinal anesthesia with ropivacaine and hydromorphone provided safe and effective analgesia after surgery for mixed hemorrhoids., Methods: This single-center, double-blind pilot study included patients with mixed hemorrhoids who underwent a procedure for prolapse and hemorrhoids (PPH) and external hemorrhoidectomy under spinal anesthesia at Zhejiang Hospital, China (October 2020 to December 2020). Patients were randomized to a hydromorphone group (spinal anesthesia with 0.5% ropivacaine and 75  μ g hydromorphone) or morphine group (spinal anesthesia with 0.5% ropivacaine and 150  μ g morphine). Pain scores (numerical rating scale), incidences of vomiting and itching, and length of hospital stay (LoS) were recorded at 6, 12, 18, and 24 hours after surgery., Results: The analysis included 40 patients in each group. Median (interquartile range) pain score in the hydromorphone group was higher than that in the morphine group at 12 hours (1 (0-2] vs. 0 (0-2), p =0.044) but not significantly different between groups at 6 hours (0 (0-1) vs. 0 (0-0) p =0.228), 18 hours (2 (2-3) vs. 2 (1-3) p =0.060) or 24 hours (2 (2-3) vs. 2 (1-3) p =0.081). The hydromorphone group had a lower incidence of pruritus than the morphine group (47.5% vs. 67.5%, p =0.018). There were no significant differences between groups in vomiting incidence or LoS., Conclusion: In patients with mixed hemorrhoids, spinal anesthesia with ropivacaine/hydromorphone has a comparable analgesic effect and a lower incidence of pruritus during the first 24 hours after surgery than spinal anesthesia with ropivacaine/morphine., Competing Interests: The authors declare that they have no conflicts of interest regarding the publication of this article., (Copyright © 2022 Xuejing Luo et al.)

Purpose: Hemorrhoidal disease (HD) is a widespread condition severely influencing patients' quality of life. Recently, the large diffusion of stapled hemorrhoidopexy has revealed a new unexpected pathological entity: the asymmetric mucosal prolapse. We aimed to assess the outcomes of the sectorial longitudinal augmented prolapsectomy (SLAP), a technique dedicated to asymmetric prolapse, in terms of HD symptoms, prolapse recurrence, and rectal stenosis., Methods: Patients affected by III-IV-degree symptomatic HD with asymmetric mucosal prolapse undergone SLAP of 1 or 2 hemorrhoidal columns (SLAP1 or SLAP2) were retrospectively assessed. The severity of hemorrhoid symptoms and fecal continence status were evaluated before and after surgery. Mean outcome was evaluation of medium-long-term outcomes as the occurrence of recurrence and anal or rectal stenosis. Secondary outcome was the evaluation of postoperative bleeding, reoperation rate, length of hospitalization, fecal urgency, and time to return to work., Results: We enrolled 433 patients (277 SLAP1 and 156 SLAP2). Hemorrhoidal symptoms recurrence was reported in 9 patients undergone SLAP1 and 4 patients undergone SLAP2, while prolapse recurrence occurred, respectively, in 4 and 2 patients. No major intraoperative complications occurred. An emergency reintervention for postoperative bleeding occurred in 13 cases undergone SLAP1 and in 5 patients treated with SLAP2. Fecal incontinence occurred in 8 and 4 cases of patients treated with SLAP1 and SLAP2., Conclusions: The combination of a simple hemorrhoidectomy to a mucosal rectal prolapsectomy should be part of every coloproctologist background. Promising and satisfying results can be achieved using SLAP for HD associated with asymmetric prolapse.

Background: Doppler-guided hemorrhoidal laser procedure consists of sutureless closure of terminal branches of the superior hemorrhoidal artery by laser energy. Clinical results of patients treated with this procedure were analyzed at the completion of 2-year follow-up. Primary endpoint was resolution of symptoms and secondary endpoints were recurrence rate, type of recurrences, re-operation rate, and potential predictive factors for failure., Methods: Bleeding was assessed on a score from 0 to 4 (none = 0; < 1/month = 1; 1/week = 2; > 1/week = 3; 3-4/week = 4), frequency of hemorrhoid-related symptoms with a score of 0-3 (2/year = 1; 3-5/year = 2; < 5/year = 3). Constipation and fecal incontinence were assessed by means of validated scores. Quality of life and pain at defecation were assessed using a visual analog scale of 0-10 (0 = worst possible-10 = best possible quality of life and 0 = no pain-10 = worst pain imaginable, respectively). Recurrence rate and need for re-operation were reported. Potential predictive factors of failure were analyzed by means of univariate analysis., Results: Two-hundred-eighty-four patients (183 males, 101 females; mean age: 47.5 years) were included in the trial; 8 patients were lost at follow-up. Analysis of 276 patients who completed the 2-year follow-up showed an overall resolution of symptoms in 89.9% (248/276) of patients. Statistically significant improvement of quality of life, pain reduction, bleeding and frequency of acute symptoms were reported. Of 28 patients with persistent or recurrent symptoms, 12 had pain (4.35%), 10 had bleeding (3.6%) and 6 had increasing prolapse at defecation (2.2%). Eleven out of twenty-eight patients required additional surgery. Constipation and III-IV grade hemorrhoids were associated with statistically significant higher failure rates (p = 0.046 and 0.012, respectively). Better results were reported in patients reporting preoperative high-grade pain at evacuation., Conclusions: The Doppler-guided hemorrhoidal laser procedure showed efficacy at long-term follow-up. It can be considered as 'first-line' treatment in patients with low-grade hemorrhoids suffering from bleeding, pain and recurrent acute symptoms in whom conservative treatment failed., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC part of Springer Nature.)

The choice of medical rehabilitation in patients with anal incontinence is impossible without diagnostic data revealing the mechanism of fecal incontinence. The most promising are programs of comprehensive physiotherapeutic rehabilitation based on biofeedback training. The rate of anal incompetence (AI) after hemorrhoidectomy is 1.3-12.5%. However, in addition to the organic cause (surgical trauma), functional disorders of the external sphincter and pelvic floor muscles may contribute to the pathogenesis of anal incontinence, aggravating the incontinence symptoms after surgery. Therefore, these functional disorders should be diagnosed before surgery. However, medical rehabilitation programs for anal incontinence after hemorrhoidectomy are not standardized, and functional outcomes have not been studied., Objective: To evaluate the outcomes of comprehensive rehabilitation in patients with AI after hemorrhoidectomy to improve quality of life after surgery., Materials and Methods: A retrospective study was carried out on 46 patients (mean age 53.8±15.4 years) after hemorrhoidectomy with fecal incontinence, 13 (28.3%) males and 33 (71.7%) females. The main group included 25 patients who received comprehensive rehabilitation, including biofeedback training and tibial neuromodulation (TNM) for 15 days. The control group consisted of 21 patients who received TNM at home also for 15 days. The severity of fecal incontinence was determined using the Wexner score. The functional state of the sphincter before and after surgery was assessed using the anorectal manometry (sphincterometry) (WPM Solar, the Netherlands)., Results: Comprehensive rehabilitation resulted in a statistically significant clinical improvement: a decrease in the Wexner score in both males and females. No significant differences in manometry results were observed: the anal sphincter tone increased by 16.0% in females and 10.6% in males, and contractility increased by 17.7% and 15.1%, respectively. Monotherapy with TNM in control group patients improved tone indices by 8.7% in females and 6.8% in males, and contractility by 6.2 and 5.4%, respectively, which was lower than in the main group., Conclusion: Contraindications to physiotherapeutic procedures based on electrical stimulation, extracorporeal magnetic stimulation, and magnetic translumbosacral neuromodulation determine the only possible choice of medical rehabilitation, which is the combination of biofeedback training and TNM (as superior to TNM monotherapy). If out-patient medical rehabilitation is not feasible, patients are recommended to complement the home course with a specially designed set of exercises for anal incontinence treatment.