Stapled hemorrhoidopexy: “mucosectomy or not only mucosectomy, this is the problem”

Introduction: Stapled hemorrhoidopexy was originally defined as a rectal mucosectomy. The aims of our retrospective, single-center study were to demonstrate if the excised specimen comprises only the mucosa or more wall rectal layers and if the latter excision should be considered a technical mistake with an increase in complications. Materials and Methods: We histopathologically analyzed surgical samples from patients who underwent stapled hemorrhoidopexy performed between 2014 and 2019. Patients were divided into three groups, according to the stapler used: Group A (single PPH®), Group B (double PPH®), and Group C (CPH34 HVTM). We evaluated the actual wall layers included in the stapled rectal ring. For every specimen, we reconstructed the history of the corresponding patient and the incidence of complications. Results: Of the 137 histological slides available, 13 were only mucosectomies (9.5%), and 124 presented also the submucosa and muscularis propria (90.5%)−50/58 patients in Group A, 28/28 in Group B, and 46/51 in Group C. No statistically significant difference in the rate of complications was found when stratifying patients according to the thickness of the resection [mucosectomy (M) or “full thickness” (FT)]. Discussion: Stapled hemorrhoidopexy is not a simple mucosectomy but a resection of the rectal wall with almost all its layers. This concept defines the entity of the surgical procedure and excludes a direct correlation with an increased rate of complications

Routine pathology examination in the era of value-based healthcare: the case of haemorrhoids specimens

Routine pathologic examination of specimens is a common practice with ill-defined value. The present study is the first to investigate the incidence and cost of incidental microscopic lesions in both haemorrhoidectomy and stapled haemorrhoidopexy specimens. Pathological reports of specimens obtained from haemorrhoidectomy and stapled haemorrhoidopexy procedures performed from January 2003 to May 2017 were analysed. Specimens resulting from patients treated for any disease other than haemorrhoids alone were excluded from the study. Unexpected diagnoses in the pathological report were defined as incidental diagnoses. A cost analysis was then performed. In the considered period we performed a total of 3017 procedures complying with our criteria. We found 65 (2.15%) unexpected lesions. Of the incidental diagnosis, 30 (0.99%) altered either the follow-up or the treatment. The incidences of both findings were extremely higher in haemorrhoidectomies specimens (p < 0.0001). We estimated that the cost of 14 years of routine pathological examination of haemorrhoids specimens was 133,351.4 euros, each consequential incidental diagnosis costing 4445.03 euros. The incidence of unexpected lesions in routine pathologic examination of haemorrhoidectomy and haemorrhoidopexy specimens is low but not negligible. The vast majority of incidental findings were found among haemorrhoidectomy specimens. Even though the real value of routine pathological examination of haemorrhoids specimens is still uncertain, from a clinical standpoint we were glad to suggest each patients the best follow-up and/or treatment. Future studies should assess preoperative patient's risk stratification and careful intraoperative macroscopic inspection strategies for selective pathology examination of haemorrhoids specimens

Annoyed with haemorrhoids? Risks of the emborrhoid technique

Haemorrhoids, a common ailment afflicting mostly Western patients, can produce bothersome symptoms, in particular pain, pruritus, and bleeding. There is a wide choice of surgical treatment options available for haemorrhoids in patients that cannot be treated with medical therapy, such as those that are prolapsed. Many patients refuse surgery due to the fear of potential complications; to overcome this obstacle, novel alternative techniques have been developed in recent years that are focussed on ligation or occlusion of haemorrhoidal arterial blood flow. We describe a patient who developed recto-sigmoidal ischaemia after embolization of the haemorrhoidal arteries, known as the "emborrhoid" technique, with persistence of rectal bleeding and progressive rectal stenosis

External hemorrhoidal thrombosis in the elderly patients. Conservative and surgical management

BACKGROUND: External hemorrhoidal thrombosis is a common disease with an acute anal pain as the major symptom. It is astonishing the lack of studies which investigates the most effective treatment and there are not guidelines. Furthermore nobody has evaluated this peculiar condition in elderly people. METHODS: We have considered 87 patients aged >75 years who were visited and treated for this condition in our clinic, dividing them in three groups according the curative option chosen together with them after anamnesis and an interview: a conservative medical treatment (Group A), an immediate incision and evacuation of the thrombus (Group B) and the excision of hemorrhoid with the thrombus, with hemorrhoidectomy technique (Group C). The mean follow-up was 12,3 months. We analyzed immediate pain relief and time of remission of symptoms, bleeding, recurrences and major complications. RESULTS: The Group A presented a remission of symptoms in 11,8 days, Group B in 1,58 ad Group C in 7,8 days. The recurrence rate was very similar for the first two options (19,4% and 16,1 %) and lower in the excision group (no recurrence during follow-up). Bleeding is the common adverse event observed with a high frequency in the immediate incision and evacuation of thrombus, less common in hemorrhoidectomy, that did not present major complication. Surgical option is often refused by elderly patient evaluating comorbidities in the fear of adverse events. CONCLUSIONS: The surgical treatment for EHT in elderly is safe and effective, but not the most common choice for fear of complications. Medical treatment or immediate incision of thrombus can be preferred and well accepted by elderly even if followed by a higher rate of recurrences

Safety and efficacy of Oryza sativa topical treatment in subjects with hemorrhoidal disease: a randomized, double blind, clinical trial

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 is to assess the safety and efficacy of a topical medical device (Lenoid™) in patients affected by symptomatic HD

Self-Mechanical Anal Dilation in Patients with Persistent Pain and Anal Sphincter Spasm after Hemorrhoidectomy with Radiofrequency

Abstract TITLE: SELF-MECHANICAL ANAL DILATION IN PATIENTS WITH PERSISTENT PAIN AND ANAL SPHINCTER SPASM AFTER HEMORRHOIDECTOMY WITH RADIOFREQUENCY AUTHORS (LAST NAME, FIRST NAME): Eberspacher, Chiara1; Mascagni, Domenico1; Fralleone, Lisa1; Pironi, Daniele1; Di Nardo, Domenico1; Antypas, Pavlos1; Pontone, Stefano1; Mascagni, Pietro2; Muzi, Marco G.1 INSTITUTIONS (ALL): 1. "Sapienza" University of Rome, Rome, Italy. 2. Università di Roma Tor Vergata, Rome, Italy.Background: The most hateful complication after a radiofrequency excisional treatment of grade III-IV hemorrhoids is the persistent postoperative pain associated with anal sphincter spasm that can even develop into a chronic anal stenosis; this occurs in approximately 4 % of patients, but the percentage increases when three or more piles are removed. Patients complain of pain (persistent > 20 days), difficult defecation, increase of stool frequency with narrow stools. Early use of an anal dilator can reduce the spasm, gently dilate the lumen, minimize the trauma of defecation and allow an elastic and soft healing of the tissues. Methods: Between January 2016 and June 2017 we enrolled 85 patients treated with radiofrequency hemorrhoidectomy with a minimum of three piles removed. We checked every patient at one week, three weeks and forty days. Postoperative (PO) pain assessment was accomplished by using the VAS (Visual Analog Scale) Pain Score; overall satisfaction was evaluated after 40 days with a score 1 to 10. In 35 patients (41%) we found, after three weeks, a persistent pain with a mean VAS score of 8 (6-10) and an evident spasm during the digital rectal examination. We gave all these patients stool softeners and analgesic therapy; in 19 patients (Group A) we associated the use of self-mechanical anal dilation; the other 16 patients (Group B) are the control group. Every patient performed the dilation in Sims positon, for three minutes a day, preferably before defecation, with a little size dilator (20 mm) for the first week, then with the medium (23 mm) for two weeks and for the last two weeks with the larger size (27 mm)(total time of application 35 days). Results: There were no complications with the dilator. In Group A, the pain with the insertion of the dilatator decreased very quickly with a mean VAS of 5 after three days and a mean VAS of 2 after 14 days of dilation. In the Group B the mean VAS was persistently higher with a mean VAS of 6 after four weeks and in 4/16 cases (25%) a VAS higher than 5 forty days after the operation. We observed a complete resolution of symptoms in a mean period of 18 days in the Group A, with a good satisfaction of all the patients (mean 9/10), while in the Group B there was the persistence of symptoms in 7/16 (43,7%) of patients after forty days with an overall satisfaction lower (mean 7/10). The digital examination after 40 days revealed a soft and elastic healing in Group A and a persistent reduction of the lumen with fibrosis in 4 (25%) Group B patients. Conclusion: Early self-mechanical anal dilation can be a useful, conservative, easy and not expensive procedure to reduce persistent pain and to prevent a possible anal stenosis, after radiofrequency radical hemorrhoidectomy. The anal dilation can guarantee a better late operative course and can minimize the risk of consolidated anal stenosis

Pilonidal disease mimicking anterior anal fistula and associated with posterior anal fistula: a two-step surgery. Case report

Anal fistula is a common disease originated from abscess according the cryptoglandular theory. A rare etiology is the pilonidal disease. In our case we observed a pilonidal disease mimicking an anterior perianal fistula, associated with another posterior anal fistula