Surgical Approach for Acute External Thrombosed Hemorrhoidal Disease
Condition: Hemorrhoids External Thrombosed
MeSH terms: Hemorrhoids
Study type: Observational

Summary: 
      Acute external thrombosed hemorrhoidal disease (AETHH) is one of the emergent complications
      of hemorrhoidal disease that results in pain and loss of work force. Although surgical
      excision is recommended in the treatment of AETHH in the guidelines of the American Society
      of Colorectal Surgeons (ASCRS) and the European Society of Coloproctology (ESCP), the level
      of evidence is low and it is emphasized that additional studies are needed. Therefore, the
      investigators aimed to compare the efficacy of surgical excision with medical treatment in
      the treatment of AETHH.
    

Detailed description: 
      Hemorrhoids are normal anatomical structures and are divided into internal and external
      according to the dentate line. External hemorrhoids distal to the dentate line, unlike
      internal hemorrhoids, are covered with squamous epithelium (anoderm), have somatic
      innervation, and are highly sensitive to pain.

      While internal hemorrhoidal disease causes symptoms such as painless bleeding, mucosal
      prolapse, soiling, and itching, external hemorrhoids do not cause clinical findings unless
      thrombosed. Acute constipation or excessive straining are held responsible for acute external
      thrombosed hemorrhoidal disease (AETHD). It appears as a painful, firm, purple-colored mass
      in the anoderm, and the main symptom is anal pain. The severity of pain increases in the
      first 24-48 hours after the formation of the thrombosed pack and reaches its peak. The pain
      is quite severe in the first 72-96 hours. Afterwards, with the resorption of the thrombosis,
      the severity of the pain decreases and the disease heals, leaving a skin tag behind.

      AETHD can be treated with surgical excision or conservative approaches. Conservative
      treatment includes a warm water sitz bath, analgesics, anti-inflammatory drugs. Also,
      phlebotonic drugs can be added. In the ASCRS and ESCP guidelines, early surgical excision is
      recommended for patients with acute external thrombosed hemorrhoidal disease in the first
      72-96 hours (low quality evidence 2C). Guidelines highlight the lack of controlled studies of
      AETHD treatment .

      In this study, the investigators aimed to compare early surgical excision with conservative
      treatment in terms of pain control and recurrence in the treatment of AETHD.
    

Intervention name(s): Conservative treatment; Surgical Treatment
Intervention type(s): Procedure; Procedure
Intervention description(s): Micronized purified flavonoid fraction, which is routinely used within indications in hemorrhoidal disease and recommended in ESCP and ASCRS guidelines, and licensed for use in hemorrhoidal disease by the Ministry of Health in our country, was given 2 g/day for one month.
Also, Conservative methods (fiber foods, warm shower, regulation of toilet habits, laxatives and nonsteroidal anti-inflammatory drugs) were recommended.; While the patient was in the Jack-knife position, both hips were pulled laterally with tapes, appropriate visualization was obtained, the external thrombosed pack was excised under local anesthesia, and the wound was left to heal with secondary intention.Conservative methods were recommended in the surgical group as well as in the medical group.
Observational model: Case-Control
Time perspective: Retrospective
Sampling method: Probability Sample
Study population: 
        The population of the study consisted of patients who applied to the general surgery
        outpatient clinic due to acute external thrombosed hemorrhoids disease. Patients who fully
        met the inclusion criteria and did not meet the exclusion criteria constituted the sample
        group.