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Background While open hemorrhoidectomy under local anesthesia has been shown to be more cost-effective with shorter operation times and lower complication rates, local anesthesia is still not considered as a first-line technique in low-income countries like Uganda. The objective of this trial is to compare open hemorrhoidectomy using local anesthesia versus saddle block among patients with primary uncomplicated 3rd- or 4th-degree hemorrhoids in western Uganda. Methods The protocol for a prospective equivalence randomized, double-blind controlled trial was conducted among patients with primary uncomplicated 3rd- or 4th-degree hemorrhoids. Recruitment was started in December 2021 and is expected to end in May 2022. Consenting participants who require open hemorrhoidectomy indicated at Kampala International Teaching Hospital, Uganda, will be randomized into two groups of 29 patients per arm. Discussion The primary outcome of this study is to compare the occurrences of postoperative pain following open hemorrhoidectomy using the visual analog scale in an interval of 2, 4, and 6 h and 7 days postoperatively. Furthermore, the mean operative time from the induction of anesthesia to the end of the surgical procedure as well as the cost-effectiveness of the 2 techniques will be assessed in both groups. Open hemorrhoidectomy under local anesthesia has the potential to offer benefits to patients but most importantly expediting return to baseline and functional status, shorter hospital stay by meeting the faster discharge criteria, and reduction in costs associated with reduced length of stay and complications. Trial registration Pan African Clinical Trials Registry PACTR202110667430356. Registered on 8 October 2021

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

Background There is disparity in evidence on pain assessment post open hemorrhoidectomy (OH) using local anesthesia and its use in developing countries compared to developed countries. Therefore, we conducted this study to assess the occurrence of postoperative pain following open hemorrhoidectomy under local anesthesia versus saddle block for uncomplicated 3 rd or 4 th degree hemorrhoids. Methods This was a prospective equivalence randomized, double blind controlled trial conducted from December 2021 to May 2022 among patients with primary uncomplicated 3 rd or 4 th degree hemorrhoids. Pain severity was assessed at 2, 4 and 6 h post open hemorrhoidectomy using visual analogue scale (VAS). Data was analysed using SPSS version 26 at a p  < 0.05 as statically significant using visual analogue scale (VAS). Results We recruited 58 participants in this study who underwent open hemorrhoidectomy under local anesthesia or saddle block (29 participants per group). The sex ratio was of 1.15 of female to male and a mean age of 39 ± 13. VAS was found to be different at 2 h post OH compare to other time of pain assessment but not statically significant by area under the cover (AUC) (95% CI = 486–0.773: AUC = 0.63; p  = 0.09) with a none significance by Kruskal–Wallis’s test (p:0.925). Conclusion Local anesthesia was found to be having a similar pain severity occurrence in post operative period among patients undergoing open hemorrhoidectomy for primary uncomplicated 3 rd or 4 th degree hemorrhoids. Close monitoring of pain in postoperative period is mandatory especially at 2 h to assess need of analgesia. Trial registration Pan African Clinical Trials Registry, PACTR202110667430356. Registered on 8 th October, 2021.

Purpose To evaluate the clinical efficacy and safety of different analgesic interventions in the treatment of pain after open hemorrhoidectomy by systematic review and network meta-analysis. Methods Randomized controlled trials that met the inclusion criteria in PubMed, Cochrane Library, Embase, Web of Science, Scopus, CNKI, WANFANG DATA, and VIP were searched from the date of database construction to June 28, 2022. Results Among the 13 randomized controlled trials (RCTs), 731 patients were included in the network meta-analysis. Most interventions are more effective than placebo in relieving postoperative pain. 24 h postoperative Visual Analogue Scale (VAS): glyceryl trinitrate (GTN) (mean difference (MD) − 4.20, 95% CI − 5.35, − 3.05), diltiazem (MD − 1.97, 95% CI − 2.44, − 1.51), botulinum toxin (BT) (MD − 1.50, 95% CI − 2.25, − 0.75), sucralfate (MD − 1.01, 95% CI − 1.53, − 0.49), and electroacupuncture (EA) (MD − 0.45, 95% CI − 0.87, − 0.04). 48 h postoperative VAS: diltiazem (MD − 2.45, 95% CI − 2.74, − 2.15), BT (MD − 2.18, 95% CI − 2.52, − 1.84), and sucralfate (MD − 1.41, 95% CI − 1.85, − 0.97). 7 d postoperative VAS: diltiazem (MD − 2.49, 95% CI − 3.20, − 1.78) and sucralfate (MD − 1.42, 95% CI − 2.00, − 0.85). The first postoperative defecation VAS: EA (MD − 0.70, 95% CI − 0.95, − 0.46). There are few data on intervention safety, and additional high-quality RCTs are expected to study this topic in the future. Conclusion Diltiazem ointment may be the most effective medication for pain relief following open hemorrhoidectomy, and it can dramatically reduce pain within one week of surgery. The second and third recommended medications are BT and sucralfate ointment. GTN has a significant advantage in alleviating pain 24 h after open hemorrhoidectomy, but whether it causes headache is debatable; thus, it should be used with caution. EA’s analgesic efficacy is still unknown. There was limited evidence on the safety of the intervention in this study, and it was simply presented statistically.

Injection sclerotherapy is an effective and safe treatment in selected cases. It might be used as the first treatment for I-III degree hemorrhoidal disease (HD), but also as a bridge therapy for more severe cases not amenable to invasive treatments. However, concerning the long-term recurrence rate, open excisional hemorrhoidectomy remains the gold standard in cases of III- and IV-degree HD. In this context, it is recommended to perform the excision of no more than three piles and to preserve the muco-cutaneous bridges to avoid post-operative anal stenosis. The aim of this study is to evaluate surgical outcomes and efficacy of the combined treatment of open excisional hemorrhoidectomy and the use of ST on the remnant muco-cutaneous bridges/residual piles. This was a single-center retrospective study and a total of 18 patients with IV-degree HD, aged between 18 and 75 years with symptomatic HD according to the Goligher classification, were enrolled between January 2023 and June 2023 and their follow-up continued until October 2023 after reaching 3 months of follow-up. The Hemorrhoidal Disease Symptom Score (HDSS), the Short Health Scale for HD (SHS-HD) score and the Vaizey Incontinence Score were used to assess symptoms and their impact on quality of life and continence. A total of 77.8% (14/18) of the patients were symptom-free (hemorrhoidal disease symptom score (HDSS) score = 0) after 3 months. Moreover, a statistically significant decrease in the median HDSS and short health scale for HD (SHS-HD) score was registered from 16 preoperatively (T0) to 2 at 3-month follow-up (T3). Neither post-operative bleeding nor any type of complications occurred. The use of sclerotherapy in combination with the traditional open excisional hemorrhoidectomy has shown promising results. Further structured studies are needed and greater dissemination and education of the general surgeon on the subject is necessary.

Hemorrhoids are one of the most common anorectal disorders. Open hemorrhoidectomy (OH) is the gold standard surgical technique while stapled hemorrhoidopexy (SH) [procedure for prolapsed hemorrhoids (PPH)] is a newly developed method for the surgical management of hemorrhoids. A Medline, PubMed, and Cochrane data base search was performed. Relevant papers, e.g., randomized controlled trials, review, and meta-analysis from different parts of the world have shown stapled hemorrhoidopexy is less painful and it is associated with quicker recovery, but SH is associated with higher rates of skin tags, hemorrhoid recurrence, and prolapse recurrence than conventional hemorrhoidectomy. A randomized trial was conducted from March 2014 to March 2016 at M.Y.H. Hospital Indore tertiary care center. The aim of the study was to compare the early results in 100 patients randomly allocated to undergo either stapled or open hemorrhoidectomy. Patients with grade II and III hemorrhoids were randomly allocated to undergo either stapled (50 patients) or open (50 patients) hemorrhoidectomy. Post-operative pain was assessed by means of a visual analog scale (VAS). Recovery evaluation included return to pain-free defecation and normal activities. A 6-month clinical follow-up was obtained in all patients. Operation time for stapled hemorrhoidectomy was shorter (mean 35.8 mins [range 20 to 50] minutes versus 50.2 mins [range 30 to 60] minutes, p < 0.05). Mean (range) VAS scores in the stapled group were significantly lower (VAS score after 7 days: 2.2 [2 to 5] versus 3.3 [2 to 6], p < 0.05). Resumption of routine work was significantly faster in the stapled group (8.08 days versus 16.2 days, p = 0.001). At follow-up, 4 weeks and 4 months recurrence of symptoms and fecal urgency was present in 6/50 (12%) patients in the stapled group and 2/50 (4%) in the OH group (p < 0.05). Our initial results suggest that stapled hemorrhoidectomy is an effective treatment for symptomatic second and third degree hemorrhoids but with significant complication rates on follow-up in patients compared with traditional hemorrhoidectomy.

Background Excisional haemorrhoidectomy is the gold standard technique in patients with III and IV degree haemorrhoidal disease (HD). However, it is associated with a significant rate of post-operative pain. The aim of our study was to evaluate the efficacy of mesoglycan in the post-operative period of patients who underwent open excisional diathermy haemorrhoidectomy (OEH). Methods This was a retrospective multicentre observational study. Three hundred ninety-eight patients from sixteen colorectal referral centres who underwent OEH for III and IV HD were enrolled. All patients were followed-up on the first post-operative day (T1) and after 1 week (T2), 3 weeks (T3) and 6 weeks (T4). BMI, habits, SF-12 questionnaire, VAS at rest (VASs), after defecation (VASd), and after anorectal digital examination (VASe), bleeding and thrombosis, time to surgical wound healing and autonomy were evaluated. Results In the mesoglycan group, post-operative thrombosis was significantly reduced at T2 (p < 0.05) and T3 (p < 0.005), and all patients experienced less post-operative pain at each time point (p < 0.001 except for VASe T4 p = 0.003). There were no significant differences between the two groups regarding the time to surgical wound healing or post-operative bleeding. There was an early recovery of autonomy in the mesoglycan group in all three follow-up periods (T2 p = 0.016; T3 p = 0.002; T4 p = 0.007). Conclusions The use of mesoglycan led to a significant reduction in post-operative thrombosis and pain with consequent early resumption of autonomy. Trial registration NCT04481698—Mesoglycan for Pain Control After Open Excisional HAEMOrrhoidectomy (MeHAEMO) https://clinicaltrials.gov/ct2/show/NCT04481698?term=Mesoglycan+for+Pain+Control+After+Open+Excisional+HAEMOrrhoidectomy+%28MeHAEMO%29&draw=2&rank=1

Stapled hemorrhoidopexy for prolapsing hemorrhoids is conceptually different from excision hemorrhoidectomy. It does not accompany the pain that usually occurs after resection of the sensitive anoderm. This study was carried out to evaluate the clinical outcome of stapled hemorrhoidopexy at The Aga Khan University Hospital. A sample of 140 patients with symptomatic second-, third-, and fourth-degree hemorrhoids and circumferential mucosal prolapse underwent stapled hemorrhoidopexy from July 2002 to July 2007. They were evaluated for postoperative morbidity, analgesic requirement, and recurrence. Seventy-eight percent were males and the mean age was 45 (range 16-90) years. The mean operative time was 35 (15-78) min. The mean parenteral analgesic doses during the first 24 h were 2.1. All patients received oral analgesics alone after 24 h. No significant postoperative morbidity was observed. The mean in-patient hospital stay was 1.3 (0-5) days. Patients were followed-up for 24 (range, 2-48) months. Minor local recurrence of hemorrhoids was seen in four patients and was managed by band ligation. Stapled hemorrhoidopexy procedure was found safe, well tolerated by patients with minimal parenteral analgesic use and early discharge from the hospital.

o compare the outcome of Milligan-Morgan (MMH) and Ferguson (FH) techniques for haemorrhoidectomy with regard to postoperative pain, control of bleeding, early mobilization of patients and wound healing. In this prospective, randomized clinical study conducted between January 2005 to December 2008, 213 patients with late 2(nd) degree; third or fourth degree hemorrhoids were assigned to two groups. One hundred ten patients in group A were operated by an open method and 103 patients in group B were operated by closed method. Age ranged from 22-70 years with mean age of 45.5 years. Peak incidence was between 41-50 years. Out of 213 patients, 170 (79.81%) were male and 43 (20.18%) were females. The mean ± SD operating time was significantly more in group B (31.3±4.8 min) than group A (25.2±5.6). The duration of hospitalization and duration off from work was more in group A than the group B. Wound healing was quicker in group B than the group A. Post operative pain scores were significantly low in the Group A than Group B during first 24 hours and at first bowel movements. Reactionary hemorrhage occurred in 4 (3.63%) patients of group A, no patient in group B developed this complication. Retention of urine was seen in 13 (11.81%) patients in group A and 4 (3.88%) in group B. No patient in group A developed anal stenosis, while 3 (2.91%) patients in group B developed anal stenosis. Wound infection was one (0.9%) in group A and two (1.9%) in group B. Two (3.63%) patients in group A came with recurrent hemorrhoids and in group B, only one (0.97%) patient reported recurrence. The closed technique is more beneficial with respect to postoperative pain, control of bleeding, early mobilization of patients and wound healing.

Summary BACKGROUND: The aim of this observational study was to analyze the outcome of grade-dependent treatment of hemorrhoidal disease (I–IV) in a single center. METHODS: Medical records of all patients with hemorrhoidal disease between July 2001 and December 2005 with a special emphasis on early and late complications and recurrence rate were studied. RESULTS: A total of 668 patients (284 females, 384 males; mean age 52.2, range 17–94 years) were assessed. Conservative treatment was applied in 281 (42.1%) cases, while surgery was performed in 387 patients (57.9%) following a grade-dependent strategy. Most common comorbidities were skin tags and simultaneous mucosal prolapse. Postoperative complications comprised pain (8.1%), bleeding (9.1%) and fecal incontinence (3.4%). Patients undergoing stapled hemorrhoidopexy showed significantly higher recurrence rates than after open hemorrhoidectomy (10% vs. 0%, p = 0.048). Urgency was more common in the stapled hemorrhoidopexy group (34.5% vs. 22.2%) and the incidence of anal stricture lower than in the open hemorrhoidectomy group (5.5% vs. 25%). CONCLUSIONS: Grade-dependent treatment of hemorrhoidal disease with respect to the clinical appearance and the extent of prolapse should be standard today.