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1Deparment of Surgery, Antonio Cardarelli Hospital, Naples, Italy
2Esophageal Diseases Center and GERD Unit, Buon Consiglio Hospital, Naples, Italy
3Department of Surgery, Pelvic Floor Center, AUSL-IRCCS Reggio Emilia, Reggio Emilia, Italy
4Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy
5Department of Medicine, Academy of Applied Medical and Social Sciences (Akademia Medycznych i Społecznych Nauk Stosowanych, AMiSNS), Elbląg, Poland
6Department of General Surgery, Villa Esther Clinic, Pineta Grande Hospital, Avellino, Italy
7Department of General and Emergency Surgery, AORN dei Colli/C.T.O. Hospital, Naples, Italy
8Department of General and Emergency Surgery, Hospital of Mercato San Severino, University of Salerno, Salerno, Italy
9Humanitas Castelli, Bergamo, Italy
10Department of Surgery, Pellegrini Hospital, ASL Napoli 1, Naples, Italy
11Oncologic Colorectal Unit, Sant’Andrea University Hospital, Rome, Italy
12Colorectal and Pelvic Floor Diseases Center, Santa Maria Dei Battuti Hospital, Conegliano (TV) Italy
13Department of General Surgery, Azienda Sanitaria Friuli Occidentale (ASFO), Pordenone, Italy
14Department of General Surgery, S. Maria degli Angeli Hospital, Bari, Italy
15Department of Surgery, Castelli Hospital, ASL Roma 6, Rome, Italy
16Unit of Colonproctologic and Pelvic Surgery, M.G. Vannini Hospital, Rome, Italy
17Department of General and Minimally Invasive Surgery, San Camillo Hospital, Trento, Italy
18Department of General and Specialist Surgery, AORN S.G. Moscati, Avellino, Italy
19Unit of Proctology and Pelvic Surgery, Città di Pavia Clinic, Pavia, Italy
20Department of General Surgery, Santa Marta e Santa Venera Hospital of Acireale, Catania, Italy
21Department of General and Emergency Surgery, Sandro Pertini Hospital, ASL Roma 2, Rome, Italy
22La Sapienza University of Rome, Umberto1 Polyclinic, Rome, Italy
23General Ad Urgent Surgery, U. Parini Regional Hospital, Aosta Valley, Italy
24Unit of Proctologic Surgery, Sant’Antonio Clinic, Cagliari, Italy
25Unit of General Surgery, Maggiore Hospital, Bologna, Italy
26Department of General and Oncologic Minimally Invasive Surgery, Federico II University, Naples, Italy
27Department of General Surgery, Hospital Conegliano - AULSS 2 Marca Trevigiana, Treviso, Italy
28Department of General Surgery, Sant’Antonio Hospital, University of Padova, Padova, Italy
29Department of Surgery, San Carlo di Nancy Hospital, Rome, Italy
30Department of Surgery, Santa Maria dei Battuti Hospital, Pordenone, Italy
31Department of Surgery, University Hospital of Ferrara, Ferrara, Italy
32Department of Surgery, Mater Dei Hospital, Bari, Italy
33Department of Surgery, University Aldo Moro, Bari, Italy
34Department of General and Emergency Radiology, Antonio Cardarelli Hospital, Naples, Italy
35Department of Surgery, University of Parma, Parma, Italy
36Department of Surgery, Cattinara Hospital ASUGI, Trieste, Italy
37Department of General Surgery, Sant’Omero-Val Vibrata Hospital, Teramo, Italy
38Department of Oncologic Colorectal Surgery, University Hospital S. Andrea, La Sapienza University, Rome, Italy
39Department of Surgery, Surgery Unit, Pelvic Floor Centre, Humanitas San Pio X, Milano, Italy
40Department of Surgery, Le Molinette Hospital, Torino, Italy
41Unit of General Surgery, Hospital of Cittadella - ULSS 6 Euganea, Padova, Italy
42Unit of General Surgery, S. Maria della Misericordia Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
43Unit of Surgery, San Francesco Clinic, Galatina, Lecce, Italy
44Unit of Surgery, Betania Evangelical Hospital, Naples, Italy
45Unit of General Surgery, AORN dei Colli/Monaldi Hospital, Naples, Italy
46Italian Registry of Physicians and Surgeons, Avellino, Italy
47Unit of Colonproctology, Euromedica Scientific Institut, Milano, Italy
48Unit of Surgery, Santa Marta e Santa Venera Hospital - ASP Catania, Catania, Italy
49Unit of Surgery, Sanatrix Clinic, Pineta Grande Hospital, Naples, Italy
50Department of General and Onologic Surgery, Andrea Tortora Hospital, Pagani, ASL Salerno, Salerno, Italy
51Department of Surgery, A. Moscati Hospital, ASL CE, Aversa, Italy
52Department of Surgery, Ave Gratia Plena Hospital, ALS CE, Caserta, Italy
53Department of Surgery, P. Colombo Hospital, Rome, Italy
54Department of Surgery, San Paolo Hospital, ALS NA 1, Naples, Italy
55Unit of Surgery, Madonna delle Grazie Clinic, Rome, Italy
56Week Surgery and Day Surgery Unit, AUSL Romagna Bufalini Hospital, Cesena, Italy
57Department of General and Oncological Surgery, Pierangeli Clinic, Pescara, Italy
58Department of Surgery, Federico II University, Naples, Italy
59Department of Surgery, Madonna della Fiducia Clinic, Rome, Italy
© 2024 The Korean Society of Coloproctology
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Conflict of interest
Antonio Brillantino, Pasquale Talento, and Luigi Marano are Editorial Board members of Annals of Coloproctology, but were not involved in the peer reviewer selection, evaluation, or decision process of this article. No other potential conflict of interest relevant to this article was reported.
Funding
None.
Author contributions
Conceptualization: A Brillantino; Investigation: all authors (the study group was composed by A Brillantino, AR, PT, LB, L Marano, FI, LL; all other authors were panelists of Delphi rounds); Methodology: A Brillantino; Supervision: A Brillantino; Writing–original draft: A Brillantino, L Marano; Writing–review & editing: all authors. All authors read and approved the final manuscript.
Study | Study size | Prolapse grade | Technique | Follow-up (mo) | Main result |
---|---|---|---|---|---|
Gupta et al. [172] (2011) | 48 | 3 | Doppler-guided HAL plus mucopexy vs. HAL without Doppler plus mucopexy | 12 | Similar hemorrhoid recurrence (P=0.939) |
Significantly longer operative time (P<0.003) and higher postoperative pain score (P<0.002) in the Doppler group | |||||
Schuurman et al. [171] (2012) | 82 | 2, 3 | HAL with Doppler vs. HAL without Doppler | 6 | No significant difference in symptom improvement (P>0.05) |
More complications in the Doppler group (P<0.0005) | |||||
Aigner et al. [173] (2016) | 40 | 3 | Doppler-guided HAL plus mucopexy vs. mucopexy alone (without previous separate HAL with a “z-stitch”) | 12 | No significant difference in hemorrhoid recurrence (P=0.274) |
Zhai et al. [174] (2016) | 100 | 3 | Doppler-guided HAL vs. suture-fixation mucopexy | 24 | No significant difference in bleeding (P=0.45) and prolapse recurrence (P=1.00) at 12 mo; |
Significant difference in prolapse recurrence at 24 mo in the Doppler group (P=0.030) | |||||
Alemrajabi et al. [175] (2023) | 36 | 3, 4 | Doppler-guided HAL plus mucopexy vs. HAL without Doppler plus mucopexy | 3 | No significant difference in hemorrhoidal recurrence (P=0.486) |
Study | Type of study | Study size | Prolapse grade | Stapler device | Follow-up (mo) | Primary outcome |
---|---|---|---|---|---|---|
Reboa et al. [247] (2016) | Multicenter, retrospective | 621 | 3, 4 | CPH34 HVa | 12 | Residual hemorrhoidal prolapse, 1.8% |
Recurrent hemorrhoidal prolapse, 1.9% | ||||||
Wei et al. [248] (2022) | Single-center, retrospective | 125 | 3 | TST STARR Plusb | 57.3c | Recurrence rate, 5.2% |
Sturiale et al. [236] (2023) | Single-center, retrospective | 59 | 2–4 | TST STARR Plusb | 70.5c | Recurrence rate, 5.1% |
Grade | Strength of recommendation | Benefit vs. risk | Quality of studies | Implication |
---|---|---|---|---|
1A | Strong (high-quality evidence) | Benefits clearly outweigh risks and burdens or vice versa | RCTs without important limitations or overwhelming evidence from observational studies | Strong recommendation; can apply to most patients in most circumstances without reservation |
1B | Strong (moderate-quality evidence) | Benefits clearly outweigh risks and burdens or vice versa | RCTs with important limitations or exceptionally strong evidence from observational studies | Strong recommendation; can apply to most patients in most circumstances without reservation |
1C | Strong (low- or very low-quality evidence) | Benefits clearly outweigh risks and burdens or vice versa | Observational studies or case series | Strong recommendation but may change when higher quality evidence becomes available |
2A | Weak (high-quality evidence) | Benefits closely balanced with risks and burdens | RCTs without important limitations or overwhelming evidence from observational studies | Weak recommendation; best action may differ depending on circumstances or patients’ or societal values |
2B | Weak (moderate-quality evidence) | Benefits closely balanced with risks and burdens | RCTs with important limitations or exceptionally strong evidence from observational studies | Weak recommendation; best action may differ depending on circumstances or patients’ or societal values |
2C | Weak (low- or very low-quality evidence) | Uncertainty in the estimates of benefits, risks, and burdens; benefits, risks, and burdens may be closely balanced | Observational studies or case series | Very weak recommendation; other alternatives may be equally reasonable |
Study | Study size | Prolapse grade | Technique | Follow-up (mo) | Main result |
---|---|---|---|---|---|
Gupta et al. [172] (2011) | 48 | 3 | Doppler-guided HAL plus mucopexy vs. HAL without Doppler plus mucopexy | 12 | Similar hemorrhoid recurrence (P=0.939) |
Significantly longer operative time (P<0.003) and higher postoperative pain score (P<0.002) in the Doppler group | |||||
Schuurman et al. [171] (2012) | 82 | 2, 3 | HAL with Doppler vs. HAL without Doppler | 6 | No significant difference in symptom improvement (P>0.05) |
More complications in the Doppler group (P<0.0005) | |||||
Aigner et al. [173] (2016) | 40 | 3 | Doppler-guided HAL plus mucopexy vs. mucopexy alone (without previous separate HAL with a “z-stitch”) | 12 | No significant difference in hemorrhoid recurrence (P=0.274) |
Zhai et al. [174] (2016) | 100 | 3 | Doppler-guided HAL vs. suture-fixation mucopexy | 24 | No significant difference in bleeding (P=0.45) and prolapse recurrence (P=1.00) at 12 mo; |
Significant difference in prolapse recurrence at 24 mo in the Doppler group (P=0.030) | |||||
Alemrajabi et al. [175] (2023) | 36 | 3, 4 | Doppler-guided HAL plus mucopexy vs. HAL without Doppler plus mucopexy | 3 | No significant difference in hemorrhoidal recurrence (P=0.486) |
Study | Type of study | Study size | Prolapse grade | Stapler device | Follow-up (mo) | Primary outcome |
---|---|---|---|---|---|---|
Reboa et al. [247] (2016) | Multicenter, retrospective | 621 | 3, 4 | CPH34 HV |
12 | Residual hemorrhoidal prolapse, 1.8% |
Recurrent hemorrhoidal prolapse, 1.9% | ||||||
Wei et al. [248] (2022) | Single-center, retrospective | 125 | 3 | TST STARR Plus |
57.3c | Recurrence rate, 5.2% |
Sturiale et al. [236] (2023) | Single-center, retrospective | 59 | 2–4 | TST STARR Plus |
70.5c | Recurrence rate, 5.1% |
Statement | Strength of recommendation |
---|---|
1. In patients with hemorrhoidal disease, what is the role of endoscopy? | |
1-1. In patients with suspected hemorrhoidal disease and inconclusive physical examination findings, anoscopy may be considered to confirm the diagnosis and to exclude other anal pathologies that could cause bleeding, discomfort, and pain. | Expert opinion |
1-2. In patients younger than 40 years with hematochezia of probable hemorrhoidal origin who do not have risk factors for colorectal neoplasia, flexible sigmoidoscopy is a reasonable diagnostic option to exclude other causes of bleeding in the preoperative setting. | Weak (2B) |
1-3. In patients older than 40 years with hematochezia, as well as in patients with hematochezia and risk factors for colorectal cancer, such as those reporting blood mixed with stools, colonoscopy represents the most appropriate diagnostic tool to evaluate the causes of bleeding. | Strong (1B) |
1-4. In patients undergoing colonoscopy and sigmoidoscopy, the endoscopic examination should be completed by anoscopy in order to more accurately detect anal pathologies. | Weak (2B) |
2. In patients with hemorrhoidal disease, what is the role of imaging investigations? | |
2-1. Due to the scarce available literature, no recommendations can be made regarding the use of imaging studies in patients with hemorrhoidal disease whose primary symptoms are vascular congestion, including bleeding and local discomfort. | - |
2-2. In cases where the diagnosis is doubtful, 3-dimensional endoanal ultrasound (3D-EAUS) and/or magnetic resonance imaging (MRI) may be considered to exclude anorectal abscesses or intraparietal masses. | Weak (2B) |
2-3. In patients with hemorrhoidal disease who also exhibit symptoms of obstructed defecation, imaging studies such as defecography, cystocolpoproctography, or magnetic resonance defecography may be considered. These investigations can help evaluate any coexisting morphological and functional disorders of the pelvic organs that may be associated with constipation. Such findings should be considered when planning a therapeutic strategy. | Weak (2B) |
2-4. In patients with hemorrhoidal disease who also have compromised baseline anal continence, or a history of obstetrical trauma or prior anorectal surgery, EAUS or MRI may be considered for evaluating sphincter defects. This can help identify patients at high risk of postoperative fecal incontinence and assist the surgeon in selecting the most appropriate therapeutic option. | Expert opinion |
3. In patients with hemorrhoidal disease, what is the role of functional investigations? | |
3-1. Anorectal manometry may be considered in patients with hemorrhoidal disease associated with obstructed defecation symptoms, in order to confirm the clinical suspicion of dyssynergic defecation. | Weak (2B) |
3-2. Anorectal manometry may be considered, together with EAUS, in the preoperative workup of patients with impaired baseline anal continence, in order to assess preoperative anorectal function and guide the surgeon in the choice of treatment strategy. | Expert opinion |
3-3. The preoperative evaluation of rectal sensitivity in patients with hemorrhoidal disease is particularly worth considering in subjects with expected baseline rectal hypersensitivity, such as those with a history of proctitis, irritable bowel syndrome, or previous rectal surgery, because this subset of patients may show a higher risk of postoperative urge incontinence after stapled hemorrhoidopexy and may be more safely treated with other surgical options. | Expert opinion |
4. In patients with hemorrhoidal disease, how, when, and why should nonoperative management be adopted? | |
4-1. Conservative treatment, which includes lifestyle measures (adequate water and fiber intake, appropriate bowel habits, and regular physical activity) and pharmacological therapy may improve hemorrhoidal disease symptoms. | Strong (1B) |
4-2. In patients with hemorrhoidal disease who continue to experience hard stools despite adopting lifestyle changes, fiber supplements and bulk-forming laxatives may be recommended to reduce straining and to lower the risk of exacerbated bleeding and prolapse. | Strong (1B) |
4-3. In the treatment of acute and chronic hemorrhoidal disease, the use of phlebotonics can be recommended. This is associated with a reduced risk of bleeding, pruritus, discharge, and leakage, leading to an overall improvement in symptoms. | Strong (1B) |
4-4. In the acute phase of hemorrhoidal disease, the use of sitz baths may be reasonable to induce relaxation of the sphincter muscles and to decrease inflammation and congestion of the vascular cushions. | Expert opinion |
4-5. Conservative treatment can be considered the first-line approach for grades 1 and 2 hemorrhoidal prolapse according to the Goligher classification, and as a temporary bridge to surgical management for grades 3 and 4 hemorrhoidal prolapse, also in accordance with the Goligher classification. | Expert opinion |
4-6. In patients with thrombosed or strangulated hemorrhoids, the use of a topical muscle relaxant such as nifedipine 0.3% combined with lidocaine 1.5% may be considered. | Weak (2C) |
4-7. Due to the limited literature available, no recommendations can be made regarding the use of nonsteroidal anti-inflammatory drugs, subcutaneous low-molecular-weight heparins, topical steroids, and other topical treatments based on phlebotonics or heparin, even though these treatments are commonly prescribed by proctologists for patients with hemorrhoidal disease in clinical practice. | - |
5. In patients with hemorrhoidal disease, what are the indications for operative management | |
5-1. In patients with chronic hemorrhoidal disease, operative management may be considered as the treatment of choice for advanced stages of hemorrhoidal prolapse (grades 3 and 4, according to the Goligher classification) and as a second-line therapeutic option, following the failure of conservative measures, for early stages of hemorrhoidal prolapse (grades 1 and 2, according to the Goligher classification). | Expert opinion |
5-2. Given the limited literature available, no recommendations can be made regarding the surgical treatment of acute hemorrhoidal disease accompanied by active bleeding. | - |
5-3. In patients with acute thrombosed external hemorrhoids, surgical treatment may be considered when symptoms are extremely severe, patient compliance with medical therapy is low, conservative treatments fail, there is intense anal pain resistant to standard analgesics, or the hemorrhoidal mass appears gangrenous. For all other cases, conservative management—including dietary modifications, stool softeners, oral analgesics, sitz baths, and topical application of nifedipine 0.3% with lidocaine 1.5%—should be considered the initial therapeutic strategy. | Expert opinion |
5-4. In patients with acute external thrombosed hemorrhoids that are suitable for surgical intervention, the surgical options may include excision or incision of the thrombosed hemorrhoids. The choice of procedure should take into account factors such as the logistical context, available resources, the physician's expertise, the patient's compliance, and the severity of the clinical case. However, excisional surgery under local anesthesia, when feasible, may be considered the preferred first-line option. This is due to its association with better early postoperative symptom relief and a lower recurrence rate when compared to simple incision with clot evacuation. | Weak (2C) |
5-5. In patients with acute thrombosed internal hemorrhoids, nonoperative management should be considered as the first-line therapeutic option. This approach includes manual reduction, warm sitz baths, rest, analgesia, phlebotonics, and topical therapy with anal sphincter muscle relaxant drugs. Operative management should be considered a second-line option if conservative measures fail, or as the treatment of choice in cases of hemorrhoidal strangulation complicated by necrosis, gangrene, or sepsis. | Expert opinion |
5-6. In patients with acute internal hemorrhoidal thrombosis and strangulation, without complications such as necrosis, gangrene, or sepsis, stapled hemorrhoidopexy may be considered as a surgical option. This procedure is associated with a shorter operation time, less postoperative pain, a reduced hospital stay, and an earlier return to normal activities when compared with conventional surgery. | Weak (2C) |
5-7. The surgical procedures performed in an emergency setting for acute hemorrhoidal disease may be associated with specific intraoperative difficulties and a potentially increased risk of complications. Therefore, the use of hemorrhoidopexy or excisional surgery in an emergency setting requires dedicated surgical training, benefits from the surgeon's experience, and is preferably performed in high-volume centers. This approach aims to minimize potential postoperative complications and improve patient outcomes. | Expert opinion |
6. In patients with chronic hemorrhoidal disease, what is the role of outpatient treatments? | |
6-1. Rubber band ligation (RBL), injection sclerotherapy, and infrared coagulation can alleviate symptoms of hemorrhoidal disease, such as bleeding, and may be considered treatment options for patients with grade 1 or 2 hemorrhoidal prolapse that is unresponsive to medical therapy. | Weak (2B) |
6-2. RBL, injection sclerotherapy, and infrared coagulation can be considered treatment options for patients who are unfit for surgery, for those who are unwilling to accept the complications and costs associated with surgical management, and as a bridge to surgical treatment in special cases where deferring surgery may be appropriate. | Expert opinion |
7. In patients with chronic hemorrhoidal disease, what is the role of nonexcisional procedures (Doppler-guided hemorrhoidal artery ligation [HAL] and mucopexy)? | |
7-1. Among the nonexcisional procedures, HAL and mucopexy can be considered treatment options for patients with hemorrhoidal disease that is not responsive to conservative treatment and is associated with grades 2 and 3 hemorrhoidal prolapse. | Strong (1B) |
7-2. Prior to treatment, patients should be thoroughly advised about the potential for worsening long-term outcomes that may necessitate further intervention, the likelihood of minor complications, and the small chance of major complications. | Strong (1C) |
7-3. The use of Doppler assistance in HAL appears to offer no advantage in terms of procedural efficacy and may be associated with increased operative time and postoperative pain. In patients with grade 3 hemorrhoidal prolapse, the success rate of the procedure seems to be more influenced by repositioning and securing the hemorrhoidal tissue in the anal canal via suture mucopexy, rather than by ligating the vessels. | Weak (2B) |
8. In patients with chronic hemorrhoidal disease, what is the role of nonexcisional procedures (i.e., stapled hemorrhoidopexy)? | |
8-1. Stapled hemorrhoidopexy may be considered as a treatment option in patients with hemorrhoidal disease that is unresponsive to medical therapy and is associated with grades 2 to 4 hemorrhoidal prolapse. | Strong (1A) |
8-2. Stapled hemorrhoidopexy may be considered a surgical option, particularly in patients with hemorrhoidal disease who also experience symptoms of obstructed defecation. | Expert opinion |
8-3. Among the various devices available for stapled hemorrhoidopexy, new generation staplers may provide the option to select the most appropriate surgical technique and adjust the amount of tissue excision based on the extent of the prolapse. | Expert opinion |
8-4. The use of next generation devices for stapled hemorrhoidopexy could result in better long-term outcomes and a reduced rate of complications. | Weak (2C) |
8-5. All patients eligible for stapled hemorrhoidopexy should receive a detailed informed consent document that explains the benefits and risks associated with the surgical procedure. | Expert opinion |
9. In patients with chronic hemorrhoidal disease, what is the role of emerging technologies? | |
9-1. Hemorrhoidal laser procedure (HeLP) may represent a valuable treatment option, particularly for patients with low-grade (grade 1) bleeding hemorrhoidal prolapse. It potentially offers the advantage of not necessitating general or spinal anesthesia. | Weak (2C) |
9-2. Laser hemorrhoidoplasty (LHP) and the Rafaelo procedure (radiofrequency ablation of hemorrhoids under local anesthetic) may be considered as treatment options for patients with hemorrhoidal disease that is unresponsive to conservative treatment and is associated with grades 2 and 3 hemorrhoidal prolapse. | Weak (2C) |
9-3. Prior to treatment, patients should be carefully advised about the possibility of worsening long-term outcomes that may necessitate further intervention, and they should be informed about the potential for minor complications. | Expert opinion |
10. In patients with chronic hemorrhoidal disease, what is the role of excisional procedures? | |
10-1. Hemorrhoidectomy may be considered as a treatment option in patients with high-grade hemorrhoidal prolapse (grades 3 and 4), especially in those with combined grade 4 prolapse and external pathological hemorrhoids. | Strong (1A) |
10-2. Patients undergoing hemorrhoidectomy should receive a detailed informed consent document that explains the long-term benefits in comparison to the early postoperative drawbacks, as well as the potential short- and long-term complications. | Expert opinion |
10-3. Hemorrhoidectomy should be considered as a treatment option for patients with recurrent high-grade hemorrhoidal prolapse following nonexcisional procedures. | Expert opinion |
10-4. Open and closed hemorrhoidectomy show similar outcomes, although closed hemorrhoidectomy has been associated with a reduced risk of bleeding and more rapid healing. | Strong (1A) |
10-5. The use of a harmonic scalpel or radiofrequency devices for hemorrhoidectomy may be associated with a shorter operative time, reduced intraoperative blood loss, and less postoperative pain compared to conventional surgery. | Strong (1B) |
GRADE, Grading of Recommendations, Assessment, Development, and Evaluations; RCT, randomized controlled trial.
HAL, hemorrhoidal artery ligation.
Frankenman International Ltd. Touchstone International Medical Science Co Ltd. Median.