Prospective randomised clinical trial of single versus double purse-string stapled mucosectomy in the treatment of prolapsed haemorrhoids The HubBLe Trial: haemorrhoidal artery ligation (HAL) versus rubber band ligation (RBL) for symptomatic second- and third-degree haemorrhoids: a multicentre randomised controlled trial and health-economic evaluation. Does a more extensive mucosal excision prevent haemorrhoidal recurrence after stapled haemorrhoidopexy? Long‐term outcome of a randomized controlled trial Haemorrhoidectomy: randomised controlled clinical trial of Ligasure compared with Milligan-Morgan operation. A validated severity score for haemorrhoids as an essential prerequisite for future haemorrhoid trials Doppler-guided transanal haemorrhoidal dearterialization for haemorrhoids: results from a multicentre trial. PPH versus THD: a comparison of two techniques for III and IV degree haemorrhoids. Personal experience. Comparison of stapled haemorrhoidopexy with traditional excisional surgery for haemorrhoidal disease (eTHoS): a pragmatic, multicentre, randomised controlled trial Treatment of grade III and IV haemorrhoidal disease with PPH or THD. A randomized trial on postoperative complications and short-term results Randomized clinical trial comparing LigaSure haemorrhoidectomy with open diathermy haemorrhoidectomy Doppler-guided haemorrhoidal artery ligation with recto anal repair: a new technique for the treatment of symptomatic haemorrhoids Stapled versus excision haemorrhoidectomy: long-term follow up of a randomised controlled trial Conventional haemorrhoidectomy, stapled haemorrhoidectomy, Doppler guided haemorrhoidectomy artery ligation; post operative pain and anorectal manometric assessment. [Haemorrhoidectomy: conventional excision versus resection with the circular stapler. Prospective, randomized study]. Stapled mucosectomy for acute thrombosed circumferentially prolapsed piles: a prospective randomized comparison with conventional haemorrhoidectomy Transanal haemorrhoidal dearterialization (THD) for selected fourth-degree haemorrhoids Transanal haemorrhoidal artery echodoppler ligation and anopexy (THD) is effective for II and III degree haemorrhoids: a prospective multicentric study Prospective evaluation of stapled haemorrhoidopexy versus transanal haemorrhoidal dearterialisation for stage II and III haemorrhoids: three-year outcomes Open versus closed day-case haemorrhoidectomy: is there any difference? Stapled haemorrhoidectomy in Chinese patients: a prospective randomised control study. Haemorrhoidal artery ligation versus rubber band ligation for the management of symptomatic second-degree and third-degree haemorrhoids (HubBLe): a multicentre, open-label, randomised controlled trial Discussion sections in reports of controlled trials published in general medical journals: islands in search of continents? A randomised trial comparing submucosal haemorrhoidectomy with radiofrequency bistoury vs. diathermic haemorrhoidectomy.
Background and aims Despite the excellent results published on circular stapled mucosectomy ( CSM ) , there is still some concern about the application of PPH-33 in the advanced haemorrhoidal disease , where a major prolapse may lead to insufficient resection and ensuing early recurrence . This study is aim ed at comparing the outcomes after single purse-string CSM versus double purse-string CSM . Patients and methods A prospect i ve r and omised clinical trial of single versus double purse-string CSM for grade III – IV symptomatic haemorrhoids was used . One hundred consecutive patients were r and omised to single ( group 1 , N=50 ) versus double purse-string CSM ( group 2 , N=50 ) . Results The mean age was 50.7 years , with a predominance of males ( 63 vs. 37 ) . Haemorrhoids were classified as grade III in 59 % and grade IV in 41 % of the patients . Mean follow-up was 26 months . Demographic and clinical features showed no differences between the two groups . The size of the resected doughnut was greater in group 2 ( 4.95 vs. 3.55 cm ; p<0.05 ) , as was the distance of the suture from the dentate line ( 3.56 vs. 3.16 cm ; p<0.05 ) . Early postoperative pain was significantly less in group 2 ( linear analogue scale from 0 to 10 ) , 2.08 vs. 3.56 ( p<0.001 ) . Postoperative haemorrhage was absent or minimal in 79 % of patients . Three patients from group 1 reported persistent pain that was resolved within the first few postoperative months . There were two recurrences in group 1 . Conclusion Double purse-string CSM resects a greater doughnut , increases the distance of the staple suture from the dentate line and reduces early postoperative pain in comparison to single purse-string CSM . Larger series are necessary to assert whether recurrence is lower BACKGROUND Optimal surgical intervention for low- grade haemorrhoids is unknown . Rubber b and ligation ( RBL ) is probably the most common intervention . Haemorrhoidal artery ligation ( HAL ) is a novel alternative that may be more efficacious . OBJECTIVE The comparison of HAL with RBL for the treatment of grade II/III haemorrhoids . DESIGN A multicentre , parallel-group r and omised controlled trial . PERSPECTIVE UK NHS and Personal Social Services . SETTING 17 NHS Trusts . PARTICIPANTS Patients aged ≥ 18 years presenting with grade II/III ( second- and third-degree ) haemorrhoids , including those who have undergone previous RBL . INTERVENTIONS HAL with Doppler probe compared with RBL . OUTCOMES Primary outcome - recurrence at 1 year post procedure ; secondary outcomes - recurrence at 6 weeks ; haemorrhoid severity score ; European Quality of Life-5 Dimensions , 5-level version ( EQ-5D-5L ) ; Vaizey incontinence score ; pain assessment ; complications ; and cost-effectiveness . RESULTS A total of 370 participants entered the trial . At 1 year post procedure , 30 % of the HAL group had evidence of recurrence compared with 49 % after RBL [ adjusted odds ratio ( OR ) = 2.23 , 95 % confidence interval ( CI ) 1.42 to 3.51 ; p = 0.0005 ] . The main reason for the difference was the number of extra procedures required to achieve improvement/cure . If a single HAL is compared with multiple RBLs then only 37.5 % recurred in the RBL arm ( adjusted OR 1.35 , 95 % CI 0.85 to 2.15 ; p = 0.20 ) . Persistence of significant symptoms at 6 weeks was lower in both arms than at 1 year ( 9 % HAL and 29 % RBL ) , suggesting significant deterioration in both groups over the year . Symptom score , EQ-5D-5L and Vaizey score improved in both groups compared with baseline , but there was no difference between interventions . Pain was less severe and of shorter duration in the RBL group ; most of the HAL group who had pain had mild to moderate pain , resolving by 3 weeks . Complications were low frequency and not significantly different between groups . It appeared that HAL  was not cost-effective compared with RBL . In the base-case analysis , the difference in mean total costs was £ 1027 higher for  HAL . Quality -adjusted life-years ( QALYs ) were higher for HAL ; however , the difference was very small ( 0.01 ) result ing in an incremental cost-effectiveness ratio of £ 104,427 per additional QALY . CONCLUSIONS At 1 year , although HAL result ed in fewer recurrences , recurrence was similar to repeat RBL . Symptom scores , complications , EQ-5D-5L and continence score were no different , and patients had more pain in the early postoperative period after HAL . HAL is more expensive and unlikely to be cost-effective in terms of incremental cost per QALY . LIMITATIONS Blinding of participants and site staff was not possible . FUTURE WORK The incidence of recurrence may continue to increase with time . Further follow-up would add to the evidence regarding long-term clinical effectiveness and cost-effectiveness . The polysymptomatic nature of haemorrhoidal disease requires a vali date d scoring system , and the data from this trial will allow further assessment of validity of such a system . These data add to the literature regarding treatment of grade II/III haemorrhoids . The results dovetail with results from the eTHoS study [ Watson AJM , Hudson J , Wood J , Kilonzo M , Brown SR , McDonald A , et al. Comparison of  stapled haemorrhoidopexy with traditional excisional surgery  for haemorrhoidal disease ( eTHoS ) : a pragmatic , multicentre , r and omised controlled trial . Lancet 2016 , in press . ] comparing stapled haemorrhoidectomy with excisional haemorrhoidectomy . Combined results will allow expansion of analysis , allowing surgeons to tailor their treatment options to individual patients . TRIAL REGISTRATION Current Controlled Trials IS RCT N41394716 . FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol . 20 , No. 88 . See the NIHR Journals Library website for further project information AIM The study aim ed in a multicentric r and omized controlled trial to define the role of a more extensive mucosal resection on recurrence of mucosal prolapse in patients with Stage III haemorrhoids undergoing stapled haemorrhoidopexy .  METHOD In all , 135 patients were r and omized to treatment with a PPH-01/03 ( Ethicon EndoSurgery ) or an EEA ( Covidien ) stapler .  They were review ed after a minimum follow-up of 4 years to determine the rate of recurrent mucosal prolapse and general condition ( wellness evaluation score ) . Postoperative bowel dysfunction was assessed using the Rome III criteria . RESULTS Eighty-seven ( 65 % ) of the 135 patients ( 48 in the EEA stapler group and 37 in the PPH group ) were available for long-term follow-up . The two groups were comparable for age , gender and duration of follow-up ( mean 49.3 ± 5.4 months and 49.0 ± 5.3 months respectively ) . In the EEA group , 11 ( 23 % ) patients had some degree of recurrent prolapse compared with 12 ( 32 % ) in the PPH group ( P = 0.409 ) . Persistence of anal bleeding was significantly higher in the PPH group ( P = 0.04 ) while the postoperative Haemorrhoid Symptom Score was significantly better in the EEA group ( 1.73 ± 1.65 vs 3.17 ± 1.94 , P < 0.001 ) . The wellness evaluation score was significantly better in the EEA group ( 1.2 ± 1.27 vs 0.6 ± 1.0 , P = 0.028 ) . Furthermore , 7 ( 15 % ) of the patients in the EEA group complained of some evacuation disturbance compared with 13 ( 36 % ) in the PPH group ( P = 0.021 ) . CONCLUSION The study failed to demonstrate any significant difference in the long-term recurrence rate of Stage III haemorrhoids using EEA or PPH . Nevertheless , use of the larger volume EEA provides better symptom resolution compared with PPH OBJECTIVE To evaluate the efficacy of the Ligasure system in the management of  haemorrhoids .  DESIGN Unblinded r and omised clinical trial . SETTING Teaching hospital , Spain . PATIENTS 112 patients with third and fourth degree haemorrhoids . INTERVENTIONS For 56 patients we used Ligasure system and a variant of Milligan and Morgan 's technique . For the other 56 , we used the traditional technique . MAIN OUTCOME MEASURES Postoperative pain . RESULTS Operating times varied from 100 seconds for each haemorrhoidal cushion with Ligasure system to the 313 seconds by the traditional technique . The blood loss was not quantifiable in patients operated on with Ligasure .  Pain was scored on a visual analogue scale . In the Ligasure group , the mean scores were 4.9 ( immediate postoperative period ) and 2.3 ( 24 hours later ) . In the other group , the scores were 7.8 and 6.9 . These differences were significant . CONCLUSION Haemorrhoidectomy using Ligasure as a technical variant of Milligan and Morgan 's technique has important advantages Background There is a lack of st and ardised outcomes for haemorrhoidal disease making comparison between trials difficult . A need for a very well vali date d severity score is essential to facilitate meta- analysis of comparative studies , enabling evidence -based clinical practice . Methods The Hubble trial provides a large cohort of patients with haemorrhoidal disease r and omised to rubber b and ligation ( RBL ) or haemorrhoidal artery ligation .  The  haemorrhoid severity score ( HSS )  was collected on each patient at baseline , 6 weeks and 1 year after intervention . This allows for the responsiveness of the HSS instrument to be examined and compared with a more specific instrument , the Vaizey incontinence score ( also collected ) . Responsiveness was tested using four methods ( effect size , st and ardised response means ( SRM ) , significance of change , and responsiveness statistic ) . Results The four tests of responsiveness demonstrated that the HSS was more responsive to changes in the patient ’s health status following both of the interventions compared to the Vaizey question naire . For example , between baseline and 6 weeks , the RBL intervention effect size scores and SRM calculations indicated a non-significant small amount of change ( 0.20 and 0.16 respectively ) . However , using the HSS , the effect size and SRM demonstrated a large magnitude of change ( 1.12 and 1.01 , respectively ) which was significant . Similar results were observed at 1 year . Significance of change scores and the index of responsiveness were also higher for the HSS question naire than the Vaizey across both treatment modalities . Conclusions The HSS is a highly responsive tool for the detection of changes in haemorrhoid symptoms . It should form an essential patient-reported outcome tool for future studies on haemorrhoidal disease AIM This multicentre study , based on the largest patient population ever published , aims to evaluate the efficacy of Doppler-guided transanal haemorrhoidal dearterialization ( THD Doppler ) in the treatment of symptomatic haemorrhoids and to identify the factors predicting failure for an effective mid-term outcome . METHOD Eight hundred and three patients affected by Grade II ( 137 , 17.1 % ) , III ( 548 , 68.2 % ) and IV ( 118 , 14.7 % ) symptomatic haemorrhoidal disease underwent THD Doppler , with a rectal mucopexy in patients with haemorrhoidal prolapse . The disease was assessed through a specifically design ed symptom question naire and scoring system . A uni- and multivariate analyses of the potential predictive factors for failure were performed . RESULTS The morbidity rate was 18.0 % , represented mainly by pain or tenesmus ( 106 patients , 13.0 % ) . Acute bleeding requiring surgical haemostasis occurred in seven patients ( 0.9 % ) . No serious or life-threatening complications occurred . After a mean follow-up period of 11.1 ± 9.2 months , the overall success rate was 90.7 % ( 728 patients ) , with a recurrence of haemorrhoidal prolapse , bleeding , and both symptoms in 51 ( 6.3 % ) , 19 ( 2.4 % ) and 5 ( 0.6 % ) patients , respectively . Sixteen out of 47 patients undergoing re-operation had a conventional haemorrhoidectomy . All the symptoms were significantly improved in each domain of the score ( P < 0.0001 ) . At multivariate analysis the absence of morbidity and performance of a distal Doppler-guided dearterialization were associated with a better outcome . CONCLUSION THD Doppler is a safe and effective therapy for haemorrhoidal disease . If this technique is to be employed , an accurate distal Doppler-guided dearterialization and a tailored mucopexy are m and atory to contain and reduce the symptoms AIM The aim of our study was to evaluate , through prospect i ve r and omized study , the outcome and the immediate and late complications of the two types of surgery most widely used for degree III-IV haemorrhoids . METHODS A total of 122 patients with degree III and IV hemorrhoids were elected for surgical intervention and , r and omly , underwent  surgery for PPH or THD . We assessed the most common immediate postoperative complications . The patients have been followed for three months with a mean follow-up at 1 month and 3 months after surgery . Parameters taken into consideration were : bleeding , pain at rest and after evacuation , soiling , constipation and tenesmus . RESULTS Five patients in PPH group ( 7.9 % ) had a major postoperative bleeding , whereas no such episode occurred in THD group ( P = ns ) . In percentage terms , VAS score was lower in THD group than in PPH group , although the difference was not statistically significant . Finally parameters values observed , during the follow-up , proved to be lower for THD group compared to PPH group . CONCLUSION PPH and THD are two surgical treatments for degree III and IV haemorrhoids with low perioperative complications and good results in the short term . However , our experience shows that better results in terms of pain and fewer postoperative complications are obtained after THD surgery , such surgery is less invasive and more adaptable to the needs of day surgery Summary Background Two commonly performed surgical interventions are available for severe ( grade II – IV ) haemorrhoids ;  traditional excisional surgery and stapled haemorrhoidopexy . Uncertainty exists as to which is most effective . The eTHoS trial was design ed to establish the clinical effectiveness and cost-effectiveness of stapled haemorrhoidopexy compared with traditional excisional surgery . Methods The eTHoS trial was a large , open-label , multicentre , parallel-group , pragmatic r and omised controlled trial done in adult participants ( aged 18 years or older ) referred to hospital for surgical treatment for grade II – IV haemorrhoids . Participants were r and omly assigned ( 1:1 ) to receive either traditional excisional surgery or stapled haemorrhoidopexy . R and omisation was minimised according to baseline EuroQol 5 dimensions 3 level score ( EQ-5D-3L ) , haemorrhoid grade , sex , and centre with an automated system to stapled haemorrhoidopexy or traditional excisional surgery . The primary outcome was area under the quality of life curve ( AUC ) measured with the EQ-5D-3L descriptive system over 24 months , assessed according to the r and omised groups . The primary outcome measure was analysed using linear regression with adjustment for the minimisation variables . This trial is registered with the IS RCT N registry , number IS RCT N80061723 . Findings Between Jan 13 , 2011 , and Aug 1 , 2014 , 777 patients were r and omised ( 389 to receive  stapled haemorrhoidopexy and 388 to receive  traditional excisional surgery ) . Stapled haemorrhoidopexy was less painful  than traditional excisional surgery in the short term and surgical complication rates were similar between groups . The EQ-5D-3L AUC score was higher in the traditional excisional surgery group than the stapled haemorrhoidopexy group over 24 months ; mean difference −0·073 ( 95 % CI −0·140 to −0·006 ; p=0·0342 ) . EQ-5D-3L was higher for stapled haemorrhoidopexy in the first 6 weeks after surgery , the traditional excisional surgery group had significantly better quality of life scores than the stapled haemorrhoidopexy group . 24 ( 7 % ) of 338 participants who received stapled haemorrhoidopexy and 33 ( 9 % ) of 352 participants who received traditional excisional surgery  had serious adverse events . Interpretation As part of a tailored management plan for haemorrhoids , traditional excisional surgery should be considered over stapled haemorrhoidopexy as the surgical treatment of choice . Funding National Institute for Health Research Health Technology Assessment programme Purpose Haemorrhoidal disease is a frequently occurring entity in the western world . The Procedure for prolapse and haemorrhoids ( PPH ) and transanal haemorrhoidal dearterialisation ( THD ) are the most important surgical treatments that respect normal anal anatomy . This is the first r and omized trial that compares both techniques in the treatment of grade III and IV haemorrhoids . Methods Patients with grade III or IV haemorrhoids were r and omized between PPH and THD . Patients were seen after 1 week , 3 weeks and 6 weeks postoperatively . Primary endpoint was resolved symptoms 6 weeks postoperatively . Secondary endpoints were pain , measured with a visual analogue scale ( VAS ) after 1 day , 1 week and 3 weeks , and complications Results Eighteen patients were allocated to PPH versus 23 to THD . Success rates after 6 weeks were 83 % in the PPH group versus 78 % in the THD group . VAS scores were significantly lower after 1 day and 1 week in the THD group , but equalled out after 3 weeks . Twelve percent of the patients after PPH and 4 % after THD needed an urgent readmission to treat an acute bleeding . Overall complication rates did not differ significantly . Conclusion Both PPH and THD are safe treatments for grade III and IV haemorrhoids with acceptable complication rates and good short-term results . THD might be the preferred treatment because it carries the similar complication rate and short-term results , but results in less postoperative pain when compared with PPH . Moreover , it is a less invasive , more easily learned and less costly procedure Background Milligan-Morgan excision haem-orrhoidectomy remains a very popular treatment modality for third and fourth degree haemorrhoids due to its cost effectiveness and good long-term results . The LigaSure tissue-sealing device is an alternative technique used in haemorrhoidectomy that has been shown to produce favourable results . The aim of this study was to assess the effectiveness of the LigaSure tissue sealing device in comparison with conventional diathermy haemorrhoidectomy Methods A prospect i ve clinical trial was conducted . Patients with newly diagnosed haemorrhoids requiring haemorrhoidectomy were r and omized to either LigaSure haemorrhoidectomy or diathermy haemorrhoidectomy . Surgical technique and postoperative care was st and ardized . Outcome measures were operative time and bleeding , postoperative pain ( measured on a visual analogue scale ) and rate of wound healing Results We r and omized 44 patients , 22 to LigaSure and 22 to diathermy ; 43 patients were evaluated . They were aged between 19 and 71 years . There were no differences in patient demographics or type of haemorrhoid being operated on .  LigaSure haemorrhoidectomy had a significantly lower mean operative time and intraoperative bleeding . At 3 weeks after surgery , haemorrhoidectomy performed with LigaSure had an odds ratio for complete epithelialization of 3.1 over diathermy ( 95 % CI 1.2–8.2 ) . There was no difference in postoperative pain Conclusion LigaSure haemorrhoidectomy is superior to diathermy for open Purpose Doppler-guided haemorrhoidal artery ligation ( DGHAL ) is a minimally invasive surgical technique used to treat symptomatic haemorrhoids . In 2005 , the DGHAL proctoscope was re design ed to incorporate a window through which a recto anal repair ( RAR ) could be performed to improve the outcome in patients with significant prolapse symptoms . The aim of this study was to observe the outcome of a series of consecutive DGHAL – RAR procedures . MethodS eventy-seven consecutive patients ( 49 male ) underwent DGHAL – RAR for symptomatic haemorrhoids and were review ed for a minimum of 6 months post-surgery . Results Fifty-seven ( 74 % ) of patients presented with both prolapse and bleeding symptoms .  The median number of DGHALs performed was six , and the median number of RARs was two . Most ( 96 % ) patients were discharged the same day . At follow-up , 11 patients complained of recurrent symptoms , five of prolapse , four of bleeding and two of pruritus . Eight patients suffered with post-operative anal fissures . The procedure is recommended by 84.4 % of patients 6 weeks post-surgery . Conclusion DGHAL – RAR is safe , effective and well tolerated . It reduces the need for potentially dangerous excisional procedures . The RAR component is an effective addition to DGHAL in the short term for the treatment of prolapse , but longer follow-up will be required to demonstrate durability of the technique Advantages of the stapling procedure for haemorrhoids  include reduced postoperative pain and shortened convalescence ; however , there are few data with respect to functional and symptomatic outcome . At a dedicated clinic , we review ed patients between Dec , 2001 , and March , 2002 , who had taken part in a r and omised controlled trial undertaken at the unit in 1999 , which compared outcomes after open or stapled haemorrhoidectomy .  We noted the presence or absence of haemorrhoid specific symptoms , and assessed overall satisfaction , continence , and quality of life .  Rigid sigmoidoscopy and an anorectal examination were also used to examine symptomatic recurrence and disease activity . At minimum follow-up of 33 months since surgery , both techniques seem to be equally effective BACKGROUND / AIMS The aim of the present article was to compare stapled haemorrhoidectomy , and haemorrhoidal artery ligation with open haemorrhoidectomy with respect to the postoperative pain , symptom control , and manometric alterations . METHODOLOGY Forty five patients with third or fourth-degree haemorrhoids were r and omly classified into three groups ; first group managed by stapled haemorrhoidectomy , second group managed by conventional haemorrhoidectomy and third group managed by Doppler guided haemorrhoidal artery ligation . ( 15 patients each ) Preoperative and 12 weeks postoperative anorectal manometry were done for all patients . RESULTS There was a significant difference of the operative time between stapled group and  Milligan-Morgan  group ( p < 0.001 ) while no significant difference between stapled group and Doppler group . The pain scores were significantly higher in open group ( p < 0.001 ) during the first 24 hours at the time of first motion and one week after operation . Postoperative control of prolapsed symptoms was significantly better with open diathermy haemorrhoidectomy than with stapled . The control of other symptoms was similar with regard to bleeding , pain , pruritus , and incontinence scores . Anorectal manometry showed a decrease in the maximum resting pressure and maximum squeeze pressure in all groups , but this decrease was only significant in the stapled haemorrhoidectomy group . CONCLUSIONS Stapled and Doppler haemorrhoidectomy is as effective as conventional haemorrhoidectomy for the treatment of haemorrhoids , but with the exception of skin tag prolapse . There is a need for long-term follow-up for the changes in manometric parameters after haemorrhoidectomy BACKGROUND AND OBJECTIVE The goal of this study was to compare two surgical methods of treating for haemorrhoids that aim at closure of the wound : resection with a circular stapler and a conventional , closed haemorrhoidectomy . PATIENTS AND METHODS 80 patients ( 41 males , mean age 47,1 years ) with haemorrhoids stage 3 were r and omized and treated with stapler haemorrhoidectomy ( test group ; n = 40 ) or had an haemorrhoidectomy according to Fansler and And erson ( control group ; n = 40 ) . Following a st and ardized study protocol we compared postoperative results on the operating day and one week , six weeks , six months and one year afterwards uni- and multivariate analysis and we also calculated the costs . RESULTS The stapler haemorrhoidectomy proved to be the method causing significantly reduced pain in the early postoperative period so that the patients needed less pain relief . They were able to return to work earlier . One year after stapler haemorrhoidectomy there were three episodes of postoperative bleedings that required intervention , one in the control group . Six patients still had haemorrhoids stage 3 , six patients over the age of 65 had persistent anal incontinence ( I degrees according to Parks ) with proven sphincter dysfunction and disturbances in voiding their bowel with result ing deterioration of quality of life , significantly more frequent than in the control group . CONCLUSIONS Stapler haemorrhoidectomy cures stage 3 haemorrhoids on a long term basis in 84.2 % of patients , costing less than all alternative treatments . In some cases , it can be associated with postoperative complications Stapled mucosectomy has been developed as an alternative to conventional haemorrhoidectomy for the elective treatment of haemorrhoids , but has not been assessed in the emergency setting . The aim of this study was to compare this technique with a conventional procedure for acute thrombosed circumferential prolapsed haemorrhoids Background Traditional treatment of fourth-degree haemorrhoidal disease ( HD ) is conventional haemorrhoidectomy and is frequently associated with significant pain and morbidity . In recent years , the use of transanal haemorrhoidal dearterialization ( THD ) for the treatment of HD has increased . The procedure aims to decrease the arterial blood flow to the haemorrhoids . Moreover , since a rectal mucopexy to treat the prolapsing component has become part of the THD technique , this treatment is also indicated for more advanced HD . The aim of this study was to assess the possible role of THD in the treatment of fourth-degree HD . Methods All patients with non-fibrotic fourth-degree HD were offered the THD procedure with mucopexy . Excision of skin tags was added to THD and mucopexy , when needed . A specific score was used to assess HD severity , ranging from 0 ( no HD ) to 20 ( worst HD ) . The mean preoperative score was 18.1 ± 1.8 . Results Thirty-five consecutive patients ( mean age 50.4 ± 13.8 years ; 19 men ) with fourth-degree HD were prospect ively enroled . An average of 6 arteries were identified and transfixed . Mucopexy was achieved with a 3–6 sector plication of rectal mucosa . Mean operating time was 33 ± 12 min . No intraoperative complications were recorded . Postoperative morbidity included 3 ( 8.6 % ) haemorrhoidal thromboses ( 1 requiring surgery ) and 2 ( 5.7 % ) episodes of bleeding ( 1 requiring surgical haemostasis ) . Five patients ( 14.3 % ) had urinary retention requiring catheterization . At a median follow-up of 10 months ( range 2–28 months ) , symptoms had resolved or significantly improved in 33 ( 94 % ) patients . Nine patients ( 25.7 % ) reported irregular bleeding , 3 patients ( 8.6 % ) mild anal pain , 4 patients ( 11.4 % ) transient anal burning and 4 patients ( 11.4 % ) tenesmus . Ten patients ( 28.6 % ) experienced some degree of residual prolapse , significant only in 2 ( 5.7 % ) who required further surgery . There was no anorectal stenosis , and no faecal incontinence was reported . At a median follow-up of 10 months , the symptomatic score was 2.5 ± 2.5 ( P < 0.005 ) . Conclusion Transanal haemorrhoidal dearterialization seems to be a safe and effective treatment for fourth-degree HD providing a significant improvement of symptoms for the majority of patients . When present , persisting symptoms are mostly transient , occasional or limited in severity , and only a very few patients require further intervention . Larger series and longer follow-up to further assess the role of THD in this challenging group of pts Aim We report a multicentric prospect i ve study which aim ed to evaluate  Doppler‐assisted ligation of the terminal haemorrhoidal arteries  (  THD  ) for II and III degree haemorrhoids 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 r and omly 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 prospect ively . 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 Background and aims Nowadays there is still controversy as to whether open or closed haemorrhoidectomy is the surgical treatment of choice for haemorrhoidal pathology . Patients and methods We carried out a r and omised prospect i ve study in the Day Surgery Unit comparing 100 patients undergoing Milligan-Morgan haemorrhoidectomy ( group A ) versus 100 patients undergoing Ferguson haemorrhoidectomy ( group B ) for symptomatic haemorrhoids , in whom medical treatment or rubber b and ligation had failed . Results Characteristics of the population were : mean age 43.5 years , with predominance of males , 123 vs. 77 ; 88 % ASA I-II . Clinical presentation : 95 % rectal bleeding ; 87.5 % third-fourth degree . The anaesthetic technique of choice was local anaesthesia plus sedation in 180 patients ( 90 % ) . Length of surgery : 24 min ( group A ) and 30 min ( group B ) ( p = n.s . ) . Resection of three haemorrhoidal cushions was done in 87.5 % of cases . There were no re-operations or re-admissions after discharge . Symptomatic recurrence , stenosis and incontinence were not found during the follow-up of the first year . Postoperative pain during the first postoperative week was greater in the open haemorrhoidectomy group , but the difference was statistically significant ( p<0.05 ) only during bowel movements . There was complete healing in 40 % of the patients in group A and 90 % of those in group B ( p<0.05 ) after 1 month . After 1 year , the results and complications were similar in both groups ( p = n.s . ) . Conclusions Closed haemorrhoidectomy gives better results in terms of pain and healing than open haemorrhoidectomy , whereas recurrence and complications are similar after 1 year OBJECTIVE To compare stapled haemorrhoidectomy with open diathermy haemorrhoidectomy in Chinese patients with respect to the  postoperative pain , symptom control , and manometric alterations .  DESIGN Prospect i ve r and omised controlled trial . SETTING A regional general surgical unit , Hong Kong . PATIENTS Twenty-four patients with second- or third-degree haemorrhoids or who have had failed medical treatment . INTERVENTION Open diathermy haemorrhoidectomy or stapled haemorrhoidectomy . MAIN OUTCOME MEASURES Structured question naire for symptoms , anorectal manometry , transrectal ultrasound , and postoperative pain . RESULTS Stapled haemorrhoidectomy compared with open diathermy haemorrhoidectomy result ed in similar postoperative pain and drug requirements . Postoperative control of prolapse symptoms was significantly better with open diathermy haemorrhoidectomy than with stapled . The control of other symptoms was similar with regard to bleeding , pain , pruritus , and incontinence scores . Anorectal manometry showed a decrease in the maximum resting pressure and maximum squeeze pressure in both groups , but the decrease was only significant in the stapled haemorrhoidectomy group . CONCLUSIONS Stapled haemorrhoidectomy is as effective as conventional haemorrhoidectomy for the treatment of haemorrhoids , but with the exception of skin tag prolapse . There is a need for long-term follow-up for the changes in manometric parameters after haemorrhoidectomy Summary Background Optimum surgical intervention for low- grade haemorrhoids is unknown . Haemorrhoidal artery ligation ( HAL ) has been proposed as an efficacious , safe therapy while rubber b and ligation ( RBL ) is a commonly used outpatient treatment . We compared recurrence after HAL versus RBL in patients with grade II – III haemorrhoids . Methods This multicentre , open-label , parallel group , r and omised controlled trial included patients from 17 acute UK NHS trusts . We screened patients aged 18 years or older presenting with grade II – III haemorrhoids . We excluded patients who had previously received any haemorrhoid surgery , more than one injection treatment for haemorrhoids , or more than one RBL procedure within 3 years before recruitment . Eligible patients were r and omly assigned ( in a 1:1 ratio ) to either RBL or HAL with Doppler . R and omisation was computer-generated and stratified by centre with blocks of r and om sizes . Allocation concealment was achieved using a web-based system . The study was open-label with no masking of participants , clinicians , or research staff . The primary outcome was recurrence at 1 year , derived from the patient 's self-reported assessment in combination with re source use from their general practitioner and hospital records . Recurrence was analysed in patients who had undergone one of the interventions and been followed up for at least 1 year . This study is registered with the IS RCT N registry , IS RCT N41394716 . Findings From Sept 9 , 2012 , to May 6 , 2014 , of 969 patients screened , 185 were r and omly assigned to the HAL group and 187 to the RBL group . Of these participants , 337 had primary outcome data ( 176 in the RBL group and 161 in the HAL group ) . At 1 year post-procedure , 87 ( 49 % ) of 176 patients in the RBL group and 48 ( 30 % ) of 161 patients in the HAL group had haemorrhoid recurrence ( adjusted odds ratio [ aOR ] 2·23 , 95 % CI 1·42–3·51 ; p=0·0005 ) . The main reason for this difference was the number of extra procedures required to achieve improvement ( 57 [ 32 % ] participants in the RBL group and 23 [ 14 % ] participants in the HAL group had a subsequent procedure for haemorrhoids ) . The mean pain 1 day after procedure was 3·4 ( SD 2·8 ) in the RBL group and 4·6 ( 2·8 ) in the HAL group ( difference −1·2 , 95 % CI −1·8 to −0·5 ; p=0·0002 ) ; at day 7 the scores were 1·6 ( 2·3 ) in the RBL group and 3·1 ( 2·4 ) in the HAL group ( difference −1·5 , −2·0 to −1·0 ; p<0·0001 ) . Pain scores did not differ between groups at 21 days and 6 weeks . 15 individuals reported serious adverse events requiring hospital admission . One patient in the RBL group had a pre-existing rectal tumour . Of the remaining 14 serious adverse events , 12 ( 7 % ) were among participants treated with HAL and two ( 1 % ) were in those treated with RBL . Six patients had pain ( one treated with RBL , five treated with HAL ) , three had bleeding not requiring transfusion ( one treated with RBL , two treated with HAL ) , two in the HAL group had urinary retention , two in the HAL group had vasovagal upset , and one in the HAL group had possible sepsis ( treated with antibiotics ) . Interpretation Although recurrence after HAL was lower than a single RBL , HAL was more painful  than RBL . The difference in recurrence was due to the need for repeat b and ings in the RBL group . Patients ( and health commissioners ) might prefer such a course of RBL to the more invasive HAL . Funding NIHR Health Technology Assessment programme CONTEXT Several journals have adopted the Consoli date d St and ards of Reporting Trials ( CONSORT ) recommendations to make assessment of the quality of r and omized controlled trials ( RCTs ) easier . One of these recommendations is that the trial 's results be discussed in light of the totality of the available evidence . OBJECTIVE To assess the extent to which reports of RCTs published in 5 general medical journals have discussed new results in light of all available evidence . DESIGN Assessment of the discussion sections in all 26 reports of RCTs published during May 1997 in Annals of Internal Medicine , BMJ , JAMA , The Lancet , and The New Engl and Journal of Medicine . MAIN OUTCOME MEASURE The inclusion or mention of a systematic review in the discussion section of each article . RESULTS In only 2 articles were the RCT 's results discussed in the context of an up date d systematic review of earlier trials . In a further 4 articles , references were made to relevant systematic review s , but no attempts were made to integrate the results of the new trials in up date d versions of these review s. One article was probably the first published trial to address the question studied . The remaining 19 articles included no evidence that any systematic attempt had been made to set the reported trial 's results in the context of previous trials . CONCLUSION There is little evidence that journals have adequately implemented the CONSORT recommendation that results of an RCT be discussed in light of the totality of the available evidence BACKGROUND Haemorrhoid disease has become more and more frequent during the past years among western population s. Great attention has been paid in development of surgical procedures , in order to reduce post-operative pain ( the main adverse effect of surgical treatment for haemorrhoids ) and shorten execution time and hospital stay . This r and omised clinical study compares the results obtained using submucosal haemorrhoidectomy with radiofrequency vs. diathermic haemorrhoidectomy . METHODS Thirty-one patients were r and omised to undergo submucosal haemorrhoidectomy with radiofrequency bistoury ( 16 patients , Group A ) or diathermic haemorrhoidectomy ( 15 patients , Group B ) . The operating time , amount of pain and postoperative analgesic requirement , intra and post-operative complications and patient satisfaction were documented . RESULTS The mean values for operative time have been 35.8 min for group A and 23.2 min for group B. According to pain score , patients ' mean values for first day postoperative pain were 3.8 ( A ) and 5.8 ( B ) . Pain at first evacuation 4.7 ( A ) and 6.5 ( B ) . Pain at 7th postoperative day was 2.3 ( A ) and 3.7 ( B ) . Patient 's postoperative satisfaction rate was 6.0 ( A ) vs. 5.2 ( B ) at 3rd day and 6.7 ( A ) and 5.7 ( B ) at 6 months . CONCLUSIONS In spite of relatively difficult execution and longer operating times , submucosal haemorrhoidectomy with radiofrequency bistoury appears to be the most precise and accurate treatment for IV degree haemorrhoids . Performing submucosal haemorrhoidectomy with radiofrequency bistoury allows us to reduce postoperative pain , bleeding and shorten hospital stay
Scores values tended to decrease postoperatively .
The comparison between haemorrhoidal treatments is still unclear .
Attempts have been made to adopt a unifying postoperative scoring system and thus ensure adequate comparison between clinical trials .
We aim ed to systematic ally review the available outcome scores of haemorrhoidal treatment .