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1.  Haemorrhoids 
Clinical Evidence  2009;2009:0415.
Introduction
Haemorrhoids are cushions of submucosal vascular tissue located in the anal canal starting just distal to the dentate line. Incidence is difficult to ascertain as many people with the condition will never consult with a medical practitioner, although one study found 10 million people in the USA complaining of the disease.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for haemorrhoidal disease? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2008 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 44 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: closed haemorrhoidectomy, haemorrhoidal artery ligation, infrared coagulation/photocoagulation, injection sclerotherapy, open excisional (Milligan-Morgan/diathermy) haemorrhoidectomy, radiofrequency ablation, rubber band ligation, and stapled haemorrhoidectomy.
Key Points
Haemorrhoids are cushions of submucosal vascular tissue located in the anal canal starting just distal to the dentate line. Haemorrhoidal disease occurs when there are symptoms such as bleeding, prolapse, pain, thrombosis, mucus discharge, and pruritus. Incidence is difficult to ascertain as many people with the condition will never consult with a medical practitioner, although one study found 10 million people in the USA complaining of the disease.
First- and second-degree haemorrhoids are classically treated with some form of non-surgical ablative/fixative intervention, third-degree treated with rubber band ligation or haemorrhoidectomy, and fourth-degree with haemorrhoidectomy.
Rubber band ligation is known to be highly effective in treating first-, second-, and some third-degree haemorrhoids. Rubber band ligation can produce some immediate adverse effects, and the clinician should therefore always gain informed consent.
Closed haemorrhoidectomy seems an effective treatment for relieving symptoms in people with first- to fourth-degree haemorrhoids. Although effective, closed haemorrhoidectomy does appear to be associated with greater postoperative complications than haemorrhoidal artery ligation.
Open excisional haemorrhoidectomy may also be effective in treating all grades of haemorrhoids, although it produces similar levels of adverse effects to closed haemorrhoidectomy.
Infrared coagulation may be as effective as rubber band ligation and injection sclerotherapy in the treatment of first- and second-degree haemorrhoids.
We found insufficient evidence to judge the effectiveness of injection sclerotherapy, radiofrequency ablation, or haemorrhoidal artery ligation.
While stapled haemorrhoidectomy seems effective in treating people with more severe haemorrhoids, some of the adverse effects are potentially life threatening, and so the procedure should only ever be carried out by a fully trained colorectal surgeon.
PMCID: PMC2907769  PMID: 19445775
2.  Transanal haemorrhoidal dearterialisation with mucopexy versus stapler haemorrhoidopexy: a randomised trial with long-term follow-up 
Introduction
The present study aimed to compare the long-term results of transanal haemorrhoidal dearterialisation (THD) with mucopexy and stapler haemorrhoidopexy (SH) in treatment of grade III and IV haemorrhoids.
Methods
One hundred and twenty-four patients with grade III and IV haemorrhoids were randomised to receive THD with mucopexy (n=63) or SH (n=61). A telephone interview with a structured questionnaire was performed at a median follow-up of 42 months. The primary outcome was the occurrence of recurrent prolapse. Patients, investigators and those assessing the outcomes were blinded to group assignment.
Results
Recurrence was present in 21 patients (16.9%). It occurred in 16 (25.4%) in the THD group and 5 (8.2%) in the SH group (p=0.021). A second surgical procedure was performed in eight patients (6.4%). Reoperation was open haemorrhoidectomy in seven cases and SH in one case. Five patients out of six in the THD group and both patients in the SH group requiring repeat surgery presented with grade IV haemorrhoids. No significant difference was found between the two groups with respect to symptom control. Patient satisfaction for the procedure was 73.0% after THD and 85.2% after SH (p=0.705). Postoperative pain, return to normal activities and complications were similar.
Conclusions
The recurrence rate after THD with mucopexy is significantly higher than after SH at long-term follow-up although results are similar with respect to symptom control and patient satisfaction. A definite risk of repeat surgery is present when both procedures are performed, especially for grade IV haemorrhoids.
doi:10.1308/003588413X13511609958136
PMCID: PMC4132497  PMID: 23676807
Haemorrhoids; Surgery; Randomised controlled trial
3.  DG-RAR for the treatment of symptomatic grade III and grade IV haemorrhoids: a 12-month multi-centre, prospective observational study 
European Surgery  2013;45(1):26-30.
Summary
Background
Ultrasound-guided techniques represent a new treatment option in the treatment of haemorrhoids. Doppler-guided haemorrhoidal artery ligation (DG-HAL) proved efficacious in early haemorrhoidal disease, but lacks efficacy for stages III/IV. For these patients, haemorrhoidal artery ligation (HAL) has been combined with a running suture to reduce prolapsing haemorrhoidal tissue (recto-anal repair (RAR)).
Methods
A prospective observational study was conducted in 184 patients with grade III (58 %) or grade IV (42 %) haemorrhoids in seven coloproctological centres. Primary endpoints were the recurrence of symptoms and need of further treatment (medical or surgical).
Results
Post-operative complications were seen in 8 % of patients. After a follow-up of 3 months, 91 % of patients were free of symptoms and 91 % of patients were satisfied with the result. After a follow-up of 12 months, 89 % of patients were free of symptoms and 88 % were satisfied with the result. Nineteen per cent of patients received further medical or surgical treatment.
Conclusions
Doppler-guided recto-anal repair (DG-RAR) proves to be an effective treatment option for the treatment of advanced haemorrhoidal disease that shows equal results to other established treatment options.
doi:10.1007/s10353-012-0182-8
PMCID: PMC3580282  PMID: 23459115
Haemorrhoids; Haemorrhoidal artery ligation; Recto-anal repair
4.  Medical and surgical treatment of haemorrhoids and anal fissure in Crohn’s disease: a critical appraisal 
BMC Gastroenterology  2013;13:47.
Background
The principle to avoid surgery for haemorrhoids and/or anal fissure in Crohn’s disease (CD) patients is still currently valid despite advances in medical and surgical treatments. In this study we report our prospectively recorded data on medical and surgical treatment of haemorrhoids and anal fissures in CD patients over a period of 8 years.
Methods
Clinical data of patients affected by perianal disease were routinely and prospectively inserted in a database between October 2003 and October 2011 at the Department of Surgery, Tor Vergata University Hospital, Rome. We reviewed and divided in two groups records on CD patients treated either medically or surgically according to the diagnosis of haemorrhoids or anal fissures. Moreover, we compared in each group the outcome in patients with prior diagnosis of CD and in patients diagnosed with CD only after perianal main treatment.
Results
Eighty-six CD patients were included in the study; 45 were treated for haemorrhoids and 41 presented with anal fissure. Conservative approach was initially adopted for all patients; in case of medical treatment failure, the presence of stable intestinal disease made them eligible for surgery. Fifteen patients underwent haemorrhoidectomy (open 11; closed 3; stapled 1), and two rubber band ligation. Fourteen patients required surgery for anal fissure (Botox ± fissurectomy 8; LIS 6). In both groups we observed high complication rate, 41.2% for haemorrhoids and 57.1% for anal fissure. Patients who underwent haemorrhoidectomy without certain diagnosis of CD had significantly higher risk of complications.
Conclusions
Conservative treatment of proctologic diseases in CD patients has been advocated given the high risk of complications and the evidence that spontaneous healing may also occur. From these preliminary results a role of surgery is conceivable in high selected patients, but definitve conclusions can’t be made. Further randomized trials are needed to establish the efficacy of the surgical approach, giving therapeutic recommendations and guidelines.
doi:10.1186/1471-230X-13-47
PMCID: PMC3602071  PMID: 23496835
Haemorrhoids; Anal fissure; Crohn’s disease; Botox; Surgery
5.  Prospective randomised comparison of photocoagulation and rubber band ligation in treatment of haemorrhoids. 
Two hundred and sixty eight patients with haemorrhoids were allocated at random to treatment by either photocoagulation (group 1, n=141) or rubber band ligation (group 2, n=127) and followed up for one year. There was no significant difference in the symptomatic outcome of treatment between the two groups at one, four, or 12 months, irrespective of whether first or second degree haemorrhoids were treated. Side effects of treatment (bleeding or severe pain) were significantly more common after rubber band ligation (n=11) than after photocoagulation (n=2; p less than 0.01). Further outpatient treatment, however, was required significantly more often after photocoagulation (n=23) than rubber band ligation (n=6) (p greater than 0.02), and 19 patients (14 in group 1 and five in group 2; NS) subsequently had a haemorrhoidectomy. At one year 26 of 103 patients were dissatisfied after photocoagulation compared with 20 of 88 after rubber band ligation. Photocoagulation is a safe and comfortable treatment which gives long term results that are as good as those of rubber band ligation. Complications are more common after rubber band ligation, but further treatment is required more commonly after photocoagulation.
PMCID: PMC1547885  PMID: 6404472
6.  How do surgeons treat haemorrhoids? A study with special reference to Lord's procedure. 
Forty-eight patients treated for haemorrhoids by Lord's procedure have been followed up for 5 years. Preoperative anal pressure and motility studies suggest that the best long-term results occur in patients with an active internal sphincter. Anal pressure was reduced by dilatation and remained static over the next 5 years. It was not possible to predict which patients would have later recurrence of symptoms from anal pressures measured one year after dilatation. Excellent clinical results were obtained in patients with first- and second-degree haemorrhoids, but in those with third-degree haemorrhoids a completely satisfactory outcome occurred in just under half the patients. Members of the Manchester Regional Association of Surgeons completed a questionnaire concerning their methods of treating haemorrhoids. Lord's procedure was the method used most frequently, but only 11% of surgeons used it regularly for patients with third-degree haemorrhoids. One-third of the surgeons still used haemorrhoidectomy for 25% of more of all their patients. Outpatient cryosurgery and rubber-band ligation were not popular, but treatment by dietary advice alone was common.
PMCID: PMC2494076  PMID: 7137830
7.  Comparison of infrared coagulation and rubber band ligation for first and second degree haemorrhoids: a randomised prospective clinical trial. 
One hundred and thirty seven previously untreated out-patients with first and second degree haemorrhoids were allocated at random to treatment by infrared coagulation (n=66) or rubber band ligation (n=71). Complete follow up was obtained in 122 patients (60 who had undergone infrared coagulation (group 1), and 62 rubber band ligation (group 2)) at periods from three months to one year after completion of treatment. Infrared coagulation produced a satisfactory outcome in 51 patients (85%): 34 were rendered asymptomatic and 17 improved. Rubber band ligation produced a satisfactory outcome in 57 patients (92%): 33 were rendered asymptomatic and 24 improved. Both methods were equally effective in first and second degree haemorrhoids. The incidence of side effects, particularly discomfort, during and after treatment was significantly higher in those treated by rubber band ligation (p less than 0.001). This appeared to be an appreciable deterrent to future patient compliance. The number of patients losing more than 24 hours from work was higher after rubber band ligation than after infrared coagulation. The number of treatments necessary to cure symptoms did not differ significantly between the two methods. Infrared coagulation was significantly faster than rubber band ligation (p less than 0.001). Infrared coagulation is a simple, fast, and effective outpatient method for the treatment of first and second degree haemorrhoids with fewer troublesome side effects and higher patient acceptability than rubber band ligation.
PMCID: PMC1547877  PMID: 6404471
8.  Prospective trials of minor surgical procedures and high-fibre diet for haemorrhoids. 
British Medical Journal  1979;2(6196):967-969.
Two hundred and sixteen consecutive patients seen for the first time with symptomatic haemorrhoids entered trials of conservative and minor surgical treatment. They were divided into two groups according to their pretreatment maximal anal pressure. Patients with pressures of 100 cm H2O (73.7 mm Hg) or more (108 patients) were treated by anal dilatation (37), sphincterotomy (34), or high-fibre diet (37). Four and 12 months later anal dilatation had produced significantly better results than sphincterotomy or diet. Furthermore, anal dilatation was the only treatment associated with a significant reduction in anal pressure at four and 12 months. Patients with pressures under 100 cm H2O (108 patients) were treated by rubber-band ligation (35), cryosurgery (36), or diet (37). Four and 12 months later significantly more patients were improved by rubber-band ligation than by cryosurgery or diet. These results suggest that haemorrhoids in patients with excessive activity of the internal anal sphincter are best treated by anal dilatation and that in all other patients rubber-band ligation is the treatment of choice.
PMCID: PMC1596562  PMID: 389346
9.  The treatment of haemorrhoids by rubber band ligation at St Mark's hospital. 
Postgraduate Medical Journal  1980;56(662):847-849.
Two hundred and ninety-five patients with symptomatic haemorrhoids were treated by rubber band ligation as out-patients at St Mark's Hospital, London, between April 1972 and December 1975. Follow-up was possible in 260 patients of whom two-thirds were satisfied with the outcome: 69 patients had residual symptoms for which no treatment had been sought. Nineteen patients eventually required a haemorrhoidectomy.
PMCID: PMC2424831  PMID: 7267495
10.  Prospective evaluation of stapled haemorrhoidopexy versus transanal haemorrhoidal dearterialisation for stage II and III haemorrhoids: three-year outcomes 
Techniques in Coloproctology  2011;15(1):67-73.
Introduction
The aim of the study was to compare short- and medium-term outcomes of transanal haemorrhoidal dearterialisation (THD) versus stapled haemorrhoidopexy (SH) for the treatment of second- and third-degree haemorrhoids.
Methods
Patients with second- or third-degree haemorrhoids who failed conservative treatment were randomly allocated to THD or SH. Preoperative and postoperative symptoms, postoperative pain, time until return to normal activities, complications, patient satisfaction and recurrence rates were all assessed prospectively. Patients were followed up at 2, 8 months and when the study was completed.
Results
Twenty-eight patients (43% third degree) underwent THD and 24 (38% third degree) underwent SH. There were no significant differences in terms of postoperative pain, expected pain and analgesia requirements, but more THD patients returned to work within 4 days (P < 0.05). One THD patient developed a sub-mucosal haematoma after surgery, one SH patient occlusion of the rectal lumen and two rectal bleeding. At 8-month follow-up, two SH patients complained of faecal urgency. At 38-month follow-up (range 33–48 months), all short-term complications resolved. Patient satisfaction (“excellent/good outcome”, THD 89 vs. SH 87%) and recurrence rate (THD 14 vs. SH 13%) were similar in the two groups.
Conclusions
Short-term results although similar seem to suggest SH may result in increased morbidity while return to work is quicker after THD. Medium-term results demonstrate that THD and SH have similar effectiveness.
doi:10.1007/s10151-010-0667-z
PMCID: PMC3046344  PMID: 21318581
Haemorrhoids; Stapled haemorrhoidopexy; Procedure for prolapse and haemorrhoids; Transanal haemorrhoidal dearterialisation
11.  Constipation, haemorrhoids, and heartburn in pregnancy 
Clinical Evidence  2008;2008:1411.
Introduction
Constipation, heartburn, and haemorrhoids are common gastrointestinal complaints during pregnancy. Constipation occurs in 11-38% of pregnant women. Although the exact prevalence of haemorrhoids during pregnancy is unknown, the condition is common, and the prevalence of symptomatic haemorrhoids in pregnant women is higher than in non-pregnant women. The incidence of heartburn in pregnancy is reported to be 17-45%.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of interventions to prevent or treat constipation in pregnancy? What are the effects of interventions to prevent or treat haemorrhoids in pregnancy? What are the effects of interventions to prevent or treat heartburn in pregnancy? We searched: Medline, Embase, The Cochrane Library and other important databases up to July 2007 (BMJ Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found five systematic reviews, RCTs or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: Acid-suppressing drugs, anaesthetic agents (topical), antacids with or without alginates, bulk-forming laxatives, compound corticosteroid and anaesthetic agents (topical), corticosteroid agents (topical), increased fibre intake, increased fluid intake, osmotic laxatives, raising the head of the bed, reducing caffeine intake, intake of fatty foods, and the size and frequency of meals, rutosides, sitz baths, and stimulant laxatives.
Key Points
Constipation, heartburn, and haemorrhoids are common gastrointestinal complaints during pregnancy.
Constipation occurs in 11-38% of pregnant women.
Stimulant laxatives may be more effective than bulk laxatives in improving constipation in pregnancy, although adverse effects, such as abdominal pain and diarrhoea, could limit their use. Dietary fibre may improve constipation in pregnant women compared with placebo.We don't know whether increasing fluid intake improves constipation in pregnancy. However, because of other health benefits, increased fluid intake may be recommended as one of the first measures to relieve constipation.We don't have good evidence to show that bulk-forming or osmotic laxatives are of benefit for constipation in pregnancy.
Although the exact prevalence of haemorrhoids during pregnancy is unknown, the condition is common, and the prevalence of symptomatic haemorrhoids in pregnant women is higher than in non-pregnant women.
Rutosides improve the symptoms of haemorrhoids compared with placebo. However, further studies are needed to assess their potential adverse effects. We don't know whether increased fibre and fluid intake are effective in relieving the symptoms of haemorrhoids in pregnancy, although it seems reasonable to encourage pregnant women to consume a fluid- and fibre-rich diet as a preventive measure.We don't know whether stimulant laxatives, bulk-forming laxatives, or osmotic laxatives are effective in relieving symptomatic haemorrhoids in pregnancy, although, if constipation is associated with haemorrhoids, treating constipation with stimulant laxatives may relieve straining, and thereby provide some symptomatic relief.We found no good evidence assessing the effects of topical anaesthetics, topical corticosteroids, or compound topical corticosteroids plus anaesthetics to treat symptomatic haemorrhoids in pregnancy. However, despite this, women who have painful complicated haemorrhoids may be offered topical anaesthetic agents unless contraindicated.
The incidence of heartburn in pregnancy is reported to be 17-45%.
Antacids may provide effective heartburn relief in pregnancy. We don't know whether dietary and lifestyle modifications are of benefit to prevent or treat heartburn in pregnancy. However, there is consensus that lifestyle and dietary modifications, including avoiding fatty foods and caffeine, should remain first-line treatment for heartburn in pregnant women.We also don't know whether acid-suppressing drugs such as ranitidine are of benefit to treat heartburn in pregnancy.
PMCID: PMC2907947  PMID: 19450328
12.  Constipation, haemorrhoids, and heartburn in pregnancy 
Clinical Evidence  2010;2010:1411.
Introduction
Constipation, heartburn, and haemorrhoids are common gastrointestinal complaints during pregnancy. Constipation occurs in 11% to 38% of pregnant women. Although the exact prevalence of haemorrhoids during pregnancy is unknown, the condition is common, and the prevalence of symptomatic haemorrhoids in pregnant women is higher than in non-pregnant women. The incidence of heartburn in pregnancy is reported to be 17% to 45%.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of interventions to prevent or treat constipation in pregnancy? What are the effects of interventions to prevent or treat haemorrhoids in pregnancy? What are the effects of interventions to prevent or treat heartburn in pregnancy? We searched: Medline, Embase, The Cochrane Library, and other important databases up to February 2010 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found seven systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: acid-suppressing drugs; anaesthetic agents (topical); antacids with or without alginates; bulk-forming laxatives; compound corticosteroid and anaesthetic agents (topical); corticosteroid agents (topical); increased fibre intake; increased fluid intake; osmotic laxatives; raising the head of the bed; reducing caffeine intake, intake of fatty foods, and the size and frequency of meals; rutosides; sitz baths; and stimulant laxatives.
Key Points
Constipation, heartburn, and haemorrhoids are common gastrointestinal complaints during pregnancy.
Constipation occurs in between 11% and 38% of pregnant women. We don't know whether stimulant, bulk-forming, or osmotic laxatives are of benefit for constipation in pregnancy.Stimulant laxatives may be more effective than bulk laxatives in improving constipation in pregnancy, although adverse effects, such as abdominal pain and diarrhoea, could limit their use. We found limited evidence that dietary fibre may improve constipation in pregnant women compared with placebo.We don't know whether increasing fluid intake improves constipation in pregnancy. However, because of other health benefits, increased fluid intake may be recommended as one of the first measures to relieve constipation.
Although the exact prevalence of haemorrhoids during pregnancy is unknown, the condition is common, and the prevalence of symptomatic haemorrhoids in pregnant women is higher than in non-pregnant women. Rutosides improve the symptoms of haemorrhoids compared with placebo. However, further studies are needed to assess their potential adverse effects. We don't know whether increased fibre or fluid intake are effective in relieving the symptoms of haemorrhoids in pregnancy, although it seems reasonable to encourage pregnant women to consume a fluid- and fibre-rich diet as a preventive measure.We don't know whether stimulant laxatives, bulk-forming laxatives, or osmotic laxatives are effective in relieving symptomatic haemorrhoids in pregnancy, although, if constipation is associated with haemorrhoids, treating constipation with stimulant laxatives may relieve straining, and thereby provide some symptomatic relief.We found no good evidence assessing the effects of sitz baths, topical anaesthetics, topical corticosteroids, or compound topical corticosteroids plus anaesthetics to treat symptomatic haemorrhoids in pregnancy. However, despite this, women who have painful complicated haemorrhoids may be offered topical anaesthetic agents unless contraindicated.
The incidence of heartburn in pregnancy is reported to be between 17% and 45%. Antacids may provide effective heartburn relief in pregnancy. We don't know whether acid-suppressing drugs, such as ranitidine, are beneficial in treating heartburn in pregnancy.We don't know whether dietary and lifestyle modifications are beneficial in preventing or treating heartburn in pregnancy. However, recommendations have been made that lifestyle and dietary modifications, including avoiding fatty foods and reducing the size and frequency of meals, should remain first-line treatment for heartburn in pregnant women. Other lifestyle modifications that could be considered are reducing caffeine intake and raising the head of the bed.
PMCID: PMC3217736  PMID: 21418682
13.  Should rubber band ligation of haemorrhoids be performed at the initial outpatient visit? 
Despite careful technique, a proportion of patients undergoing rubber band ligation (RBL) of haemorrhoids will experience pain or discomfort. To investigate this, a group of 52 unselected patients presenting to the surgical outpatient clinic of Bristol Royal Infirmary were entered into a prospective study using questionnaires, of which 50 (96%) replied. Pain and discomfort were scored on a 10 cm visual analogue scale. Of these patients, 42 (84%) reported pain in the first 24 h; this was moderate to severe in 9 (18%); 30 (60%) had pain in the second 24 h, with 7 (14%) patients suffering moderate to severe pain. In all, 14 (28%) patients were unable to perform their normal activities on the day of treatment and a further 14 (28%) patients felt faint immediately after RBL. The results of this study indicate that pain after RBL occurs more often than previously recognised. It is suggested that informed consent be obtained before RBL and that patients should be given the opportunity to delay treatment if they so wish.
PMCID: PMC2502317  PMID: 8017813
14.  Transanal dearterialization with targeted mucopexy is effective for advanced haemorrhoids 
Colorectal Disease  2014;16(5):373-376.
Aim
Transanal haemorrhoidal dearterialization (THD) has become well established for the treatment of haemorrhoids. In this study we describe a technical modification of this technique, targeted mucopexy (THD TM), and report the results for advanced haemorrhoids.
Method
The study included a prospective evaluation of patients with Grade IV (fourth-degree) haemorrhoids operated on with the THD TM technique. This consisted of an initial dearterialization when the haemorrhoidal arteries were transfixed and a second phase of mucopexy, using a different needle from that usually used in the original technique.
Results
From January 2007 to December 2011, 31 consecutive patients with Grade IV haemorrhoids were operated on using the THD TM technique. Postoperative pain was reported by 22 (70%) patients on day 1 and 19 (61%) on day 7, while nine (30%) did not experience any pain at all. Severe pain was reported by only nine (16%) patients. At a mean follow-up of 32 months, two (6.4%) patients required a further intervention for on-going symptoms.
Conclusion
Transanal haemorrhoidal dearterialization TM is effective for advanced haemorrhoids.
What does this paper add to the literature
This paper describes a technical modification of the original transanal haemorrhoidal dearterialization technique introduced by the senior author and reports the results achieved with it in patients with Grade IV haemorrhoids. We believe the modification has allowed a significant improvement in the outcome, especially when dealing with advanced haemorrhoids.
doi:10.1111/codi.12574
PMCID: PMC4283720  PMID: 24460621
Haemorrhoids; transanal haemorrhoidal dearterialization; targeted mucopexy; haemorrhoidal artery ligation
15.  Survey of methods of treatment of haemorrhoids and complications of injection sclerotherapy. 
INTRODUCTION: This study was conducted to survey current practices in the treatment of haemorrhoids (Hs), prevalence of complications associated with injection sclerotherapy (IS) and attitudes to its use to treat anterior Hs. METHODS: Postal questionnaires were sent to 92 consultant surgeons in the South East Thames Region. They were returned anonymously. RESULTS: Seventy questionnaires were returned (76% response rate) and 61 questionnaires were used in the data analysis; 18 from coloproctologists and 43 from non-coloproctologists who treated Hs. First degree Hs were mostly treated with IS alone (76%). Second degree Hs were treated with rubber band ligation (RBL) alone (36%) or a combination of IS and RBL (36%). Third degree Hs were mostly treated with haemorrhoidectomy (76%). Nineteen surgeons (31%) reported complications using IS; 82% of these were urological. Nine surgeons (15%) did not use IS to treat anterior Hs and 10 (16%) advised their trainees not to inject anteriorly. CONCLUSIONS: IS is a common treatment of Hs. Nearly one-third of consultants reported complications, the majority of which were urological and likely to be secondary to IS of anterior Hs. It may be safer to avoid IS of anterior haemorrhoids.
PMCID: PMC2503400  PMID: 11806557
16.  Haemorrhoids--objective measurement of proctoscopic appearances. 
Postgraduate Medical Journal  1980;56(651):30-33.
The proctoscopic diagnosis of haemorrhoids may be influenced by the surgeon's knowledge of the presence or absence of associated symptoms. In this study, an observer with no knowledge of the history, was used to check the surgeon's proctoscopic findings in 12 asymptomatic controls, and 24 symptomatic patients on 2 occasions, the latter group undergoing McGivney rubber band ligation. There was very good correlation between the findings of the surgeon and the observer, indicating a lack of 'historical bias'. The documentation method designed to allow this comparison proved sufficiently accurate and reproducible to enable a correlation between haemorrhoidal mass and symptoms. Relief of symptoms after treatment correlated well with an objective reduction in haemorrhoidal mass.
PMCID: PMC2426009  PMID: 7383948
17.  Rubber band ligation of haemorrhoids in the out-patient clinic. 
Rubber band ligation (RBL) is an effective treatment for symptomatic haemorrhoids but carries significant morbidity. We performed a prospective study of 98 consecutive patients treated by RBL in the out-patient clinic. Immediate, intermediate (within 2 weeks) and late (within 2 months) complications were recorded. Immediate complications occurred in 66 (67.3%) patients. Pain was the predominant symptom in 50 patients (51%). Fifteen (15.3%) patients had vasovagal attacks and 1 (1%) had bleeding. Twenty-five patients (25.5%) were unable to perform normal activities on the day of RBL. One patient needed hospital admission for control of pain. Seventy four (75.5%) patients would have RBL if they needed further treatment for haemorrhoids. Symptomatic cure was achieved in 71 patients (72.4%). RBL is an effective treatment but with significant complications. Patients should be adequately warned, especially of pain and vasovagal attacks.
PMCID: PMC2503822  PMID: 12092868
18.  Managing haemorrhoids 
BMJ : British Medical Journal  2003;327(7419):847-851.
Increased understanding of the anatomy of haemorrhoids has led to the development of new procedures to treat them. Among the surgical options for intractable prolapsed haemorrhoids, formal haemorrhoidectomy now competes with stapled haemorrhoidopexy, which is less painful and allows a shorter convalescence but may have a higher recurrence rate and needs further long term evaluation
PMCID: PMC214027  PMID: 14551102
19.  Updated meta-analysis of randomized controlled trials comparing conventional excisional haemorrhoidectomy with LigaSure for haemorrhoids 
Techniques in Coloproctology  2008;12(3):229-239.
Background
To compare the surgical outcome of haemorrhoidectomy performed using LigaSure bipolar diathermy with conventional haemorrhoidectomy.
Methods
Only randomized and alternate allocated studies were included from the major electronic databases using the search terms “ligasure” and “haemorrhoids” Duration of operation, blood loss during operation, postoperative pain score, wound healing, in-hospital stay, time to return to normal activities and complications were assessed.
Results
The 11 trials contained a total of 1,046 patients; the largest study was based on 273 patients and two earlier studies were based on 34 patients. No significant gender mismatch between the groups was reported in any of the studies. The patients’ ages were similar between groups in the studies, as was disease severity. All 11 studies reported a shorter duration of the operation when using LigaSure compared to the conventional technique (p<0.001). The postoperative pain score (p=0.001) and blood loss during operation (p=0.001) were significantly reduced. After LigaSure haemorrhoidectomy wound healing (p=0.004) and the return to normal activities (p=0.001) were significantly faster than after conventional haemorrhoidectomy. However, the overall incidence of complications reported was not significantly different (p=0.056).
Conclusions
LigaSure is an effective instrument for haemorrhoidectomy which results in less blood loss, quicker wound healing and earlier return to work.
doi:10.1007/s10151-008-0426-6
PMCID: PMC2799011  PMID: 18679571
Meta-analysis; Haemorrhoids; Haemorrhoidectomy; LigaSure
20.  Bipolar radiofrequency-induced thermotherapy of haemorrhoids: a new minimally invasive method for haemorrhoidal disease treatment. Early results of a pilot study 
Introduction
Haemorrhoidal disease is the most frequent benign anorectal disease. Conservative, minimally invasive and surgical methods are used in the treatment of haemorrhoidal disease. Radiofrequency thermoablation is a popular new technique in the treatment of varicose veins.
Aim
Assessment of the use of the method in the treatment of haemorrhoidal disease using bipolar radiofrequency-induced thermotherapy (RFITT or so-called Celon method).
Material and methods
We used the CelonLab PRECISION (Celon AG medical instruments, Teltow, Germany) with the bipolar RFITT applicator Celon ProBREATH for the treatment of haemorrhoidal disease stages III and IV.
Results
In the Department of Surgery at the Atlas Hospital in Zlin, Czech Republic, a total of 71 patients were treated from 9/2007 to 10/2010 with this new treatment approach. The success rate was 100%, local recurrence rate was 2.8%, and medium-term satisfaction of patients who underwent the procedure was 99.5%. Complications appeared in 4.26% of cases.
Conclusions
The new RFITTH technique for treatment of advanced stages of haemorrhoidal disease is a new treatment modality with good curative response, low level of complications, minimum pain and quick return of patients to their usual activities.
doi:10.5114/wiitm.2011.30824
PMCID: PMC3627146  PMID: 23630553
haemorrhoids; radiofrequency; miniinvasive technique
21.  LigaSure Haemorrhoidectomy versus Conventional Diathermy for IV-Degree Haemorrhoids: Is It the Treatment of Choice? A Randomized, Clinical Trial 
ISRN Gastroenterology  2010;2011:467258.
Introduction. Milligan-Morgan haemorrhoidectomy performed with LigaSure system (LS) seems to be mainly effective where a large tissue demolition is required. This randomized study is designed to compare LigaSure haemorrohidectomy with conventional diathermy (CD) for treatment of IV-degree haemorrhoids. Methods. 52 patients with IV-degree haemorrhoids were randomized to two groups (conventional diathermy versus LigaSure haemorrhoidectomy). They were evaluated on the basis of the following main outcomes: mean operative time, postoperative pain, day of discharge, early and late complications. The time of recovery of work was also assessed. All patients had a minimum follow-up of twelve months (range 12–24). All data were statistically evaluated. Results. 27 patients were treated by conventional diathermy, 25 by LigaSure. The mean operative time was significantly shorter in LS, such as postoperative pain, mainly lower on the third and fourth postoperative day: moreover pain disappeared earlier in LS than CD. The time off-work was shorter in LS, while there was no difference in hospital stay and overall complications rate. Conclusions. LigaSure is an effective instrument when a large tissue demolition is required. This study supports its use as treatment of choice for IV degree haemorrhoids, even if the procedure is more expansive than conventional operation.
doi:10.5402/2011/467258
PMCID: PMC3168454  PMID: 21991510
22.  A Prospective Audit of Early Pain and Patient Satisfaction Following Out-Patient Band Ligation of Haemorrhoids 
INTRODUCTION
Information regarding early morbidity, pain and patient satisfaction following band ligation of haemorrhoids is limited. This is the first report to address these issues specifically.
PATIENTS AND METHODS
A total of 183 patients underwent the procedure over a 10-month period. Prospective data were collected using a detailed structured questionnaire regarding symptoms, analgesia requirements and patient satisfaction in the following week.
RESULTS
The response rate was 74% (135/183). Pain scores were highest 4 h following the procedure. At 1 week, 75% of patients were pain-free, with 9 (7%) still experiencing moderate-to-severe pain. About 65% required oral analgesia, most frequently on the day of procedure. Rectal bleeding occurred in 86 patients (65%) on the day after banding, persisting in 32 (24%) at 1 week. Vaso-vagal symptoms occurred in 41 patients (30%) and were commonest at the time of banding. Eighty patients (59%) were satisfied with their experience and would undergo the procedure again. Patients requiring oral analgesia and those experiencing bleeding or vaso-vagal symptoms were significantly less likely to be satisfied with the procedure. Only 57% of the patients surveyed would recommend the procedure to a friend.
CONCLUSIONS
Data from this large cohort of patients suggest that discomfort and bleeding may persist for a week or more following banding of haemorrhoids. Patients should be aware of this in order to make an informed decision as to whether to undergo the procedure, and surgeons should investigate ways of reducing it. Patient satisfaction may be further improved by more accurate counselling regarding the incidence of specific complications.
doi:10.1308/003588406X98649
PMCID: PMC1963694  PMID: 16719998
Haemorrhoids; Symptoms; Patient care; Band ligation
23.  Manual dilatation of the anus and elastic band ligature: an effective short stay alternative to formal haemorrhoidectomy for prolapsing haemorrhoids. 
Fifty patients with second or third degree haemorrhoids were treated by manual dilatation of the anus (MDA) and elastic band ligature under general anaesthesia. All patients had prolapsing haemorrhoids at presentation associated with bleeding in 46, and pain in 39. A final review by questionnaire was undertaken one to three years later, at which time 44 patients remained symptom-free. Forty-three had experienced only mild or moderate discomfort postoperatively. Mean time from operation to pursuing all normal activities was 10 days. MDA and elastic band ligature under GA is a simple, quick and effective alternative to haemorrhoidectomy in the treatment of second and third degree haemorrhoids.
PMCID: PMC2494431  PMID: 6638853
24.  Haemorrhoids: a doctor's dilemma 
Postgraduate Medical Journal  1981;57(673):683-685.
The different forms of treatment for haemorrhoids are described. These include conservative therapy, elastic band ligation, sclerotherapy, cryosurgery, anal dilatation, lateral sphincterotomy and formal surgery. Controlled trials comparing these methods of treatment indicate that surgery should be rarely performed. Of the remaining methods available, elastic band ligation or anal dilatation are recommended.
PMCID: PMC2426209  PMID: 7041106
25.  Vascular Z-shaped ligation technique in surgical treatment of haemorrhoid 
AIM: To present the effectiveness of minimal invasive vascular zet ligation in the surgical treatment of haemorrhoidal disease (HD).
METHODS: Among 138 patients with 2nd-4th grade internal HD having several complaints and operated at our hospital between 2003-2013; 116 patients who regularly attended 1-year control were included in the study. Operation times, postoperative early period pain, satisfaction score, complications and relapse details were obtained from computer records retrospectively. Visual Analogous Scale (VAS) scores were used for patient satisfaction on the 3rd, 7th and 21st days. Technique; fixed suture which is constituted by the first leg of the Z-shaped suture (to pass by the mucosa and muscular layer) was put in the pile root in order to ensure vascular ligation and fixation. The second leg of the Z-shaped suture is constituted by mobile suture and it passes by the pile mucosa and submucosa which prolapses 5-10 mm below the first suture.
RESULTS: Seventy-five of the patients (65%) were male, 41 of them (35%) were female and their age average was 41. The mean operation time was 12 ± 4.8 min. VAS/satisfaction score was found as 2.2/4.3, 1.8/4.0, 1.2/4.4 respectively on the 3rd, 7th, and 21st days. Four of the patient (3.5%) had relapse.
CONCLUSION: This technique is an easily applicable, cost efficient way of operation which increases patient satisfaction.
doi:10.4252/wjsc.v7.i1.10
PMCID: PMC4300913  PMID: 25625005
Haemorrhoids; Haemorrhoidectomy; Z ligation

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