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Puncture Vacuum Trombus Extraction with Laser Coagulation of Hemorrhoid Node in Treatment of Acute External Hemorrhoid Thrombosis: a Randomized Trial
Abstract
Objectives. To estimate the efficacy of puncture vacuum thrombus extraction with laser coagulation of hemorrhoid node in complex treatment of patients with acute thrombosed external hemorrhoids (grade I, 2). Methods. Depending on surgical intervention the patients were divided into five groups. Minimally-invasive procedure - puncture vacuum thrombus extraction with laser coagulation of cavernous capsule node being an office-based surgery (1 day) had been performed in two main groups (A and B; 30 patients per each). The incision thrombus extraction procedure was performed in patients of group C (n=24), excision thrombus extraction - in patients of group D (n=27). The patients of group E (n=30) received only conservative treatment. The comparative analysis of the results of treatment had been carried out as a result of the prospective randomized trial. Results. The least invasive technique of thrombus removal has been established to be an aspiration-puncture method. It allows the quick cupping of pain syndrome and inflammation in comparison with conservative treatment (The Mann-Whitney U Test has been used for the comparative analysis of anal discomfort (p=1,4.10-11, z = -6,6456). Simple incision thrombus extraction without destruction of hemorrhoidal tissue is not considered to be a radical procedure: recurrence disease rate reached 37,5% (p=0,007 Mann-Whitney U-Test). Hemorrhage from an intervention zone after incision thrombus extraction (group C) were noted (p=0,0006 Mann-Whitney U-Test) in 33,3%. The excision thrombus extraction (group D) is the radical procedure preventing recurrence development. However, this type of operation was accompanied by a higher rate of bleeding incidents in the incisional period (22,2%; p=0,0063 Mann-Whitney U-Test). Conclusion. The combination of active surgical tactics (the developed method of puncture thrombus extraction with coagulation of hemorrhoid node by laser radiation (1,56 microns) under tumescent local anesthesia) permits to prerent a recurrence, to reduce the number of possible complications, to decrease a pain syndrome that can result to a considerable reduction of terms of therapy.
... The rate of bleeding after hemorrhoidectomy ranges from 1% to 5%. This is bleeding that requires imposing additional ligature and stitching of the node [6] . Due to date from Mauricio De La Garza 5, [4][5][6][7] , 6% of patients complained of severe pains and they were relieved by narcotic analgesics [3] . ...
... This is bleeding that requires imposing additional ligature and stitching of the node [6] . Due to date from Mauricio De La Garza 5, [4][5][6][7] , 6% of patients complained of severe pains and they were relieved by narcotic analgesics [3] . ...
AIM: To compare the efficacy and safety of recombinant streptokinase (rSK) vs hydrocortisone acetate-based suppositories in acute hemorrhoidal disease.
METHODS: A multicenter (11 sites), randomized (1:1:1), open, controlled trial with parallel groups was performed. All participating patients gave their written, informed consent. After inclusion, patients with acute symptoms of hemorrhoids were centrally randomized to receive, as outpatients, by the rectal route, suppositories of rSK 200000 IU of one unit every 8 h (first 3 units) and afterwards every 12 h until 8 administrations were completed (schedule A), one unit every 8 h until 6 units were completed (schedule B), or 25 mg hydrocortisone acetate once every 8 h up to a maximum of 24 administrations. Evaluations were performed at 3, 5, and 10 d post-inclusion. The main end-point was the 5th-day response (disappearance of pain and bleeding, and ≥ 70% reduction of the lesion size). Time to response and need for thrombectomy were secondary efficacy variables. Adverse events were also evaluated.
RESULTS: Groups were homogeneous with regards to demographic and baseline characteristics. Fifth day complete response rates were 156/170 (91.8%; 95%CI: 87.3-96.2), 155/170 (91.2%; 95%CI: 86.6%-95.7%), and 46/170 (27.1%; 95%CI: 20.1%-34.0%) with rSK (schedule A and B) and hydrocortisone acetate suppositories, respectively. These 64.6% and 63.9% differences (95%CI: 56.7%-72.2% and 55.7%-72.0%) were highly significant (P < 0.001). This advantage was detected since the early 3rd day evaluation (68.8% and 64.1% vs 7.1% for the rSK and active control groups, respectively; P < 0.001) and was maintained even at the late 10th day assessment (97.1% and 93.5% vs 67.1% for rSK and hydrocortisone acetate, respectively; P < 0.001). Time to response was 3 d (95%CI: 2.9-3.1) for both rSK groups and 10 d (95%CI: 9.3-10.7) in the hydrocortisone acetate group. This difference was highly significant (P < 0.001). All subgroup stratified analyses (with or without thrombosis and hemorrhoid classification) showed a statistically significant advantage for the rSK groups. Thrombectomy was necessary in 4/251 and 14/133 patients with baseline thrombosis in the rSK and hydrocortisone acetate groups, respectively (P < 0.001). There were no adverse events attributable to the experimental treatment.
CONCLUSION: rSK suppositories showed a significant advantage over a widely-used over-the-counter hydrocortisone acetate preparation for the treatment of acute hemorrhoidal illness, as well as having an adequate safety profile.
The role of a mixture of phlebotonics in the treatment of acute hemorrhoid crisis is investigated to test their efficacy.
One hundred and thirty-four consecutive patients with an acute hemorrhoidal crisis recruited in five colorectal units entered the study. Sixty-six of them were randomized to receive a mixture of diosmin, troxerutin and hesperidin (group A), and 68 a placebo (group B). The main symptoms, the use of oral painkillers and the Bristol scale score were recorded at each scheduled visit and compared using both Student's t test for independent samples and the ANOVA models for repeated measures. The presence of edema, prolapse and thrombosis were also recorded and compared using the Chi-square test. Furthermore, the trend of proportions during the time of the evaluations was assessed by the Chi-square test for linear trend.
Pain, bleeding and the proportion of patients who reported persistence of edema and thrombosis decreased significantly after 12 days of treatment in group A. After 6 days, the number of paracetamol tablets taken by patients in group A was significantly lower than the amount of flavonoid mixture.
The use of a mixture of diosmin, troxerutin and hesperidin is a safe and effective mean of managing symptoms of acute hemorrhoidal disease. Furthermore, in patients receiving treatment, there was faster control and lower persistence of edema and thrombosis.
It is unknown whether surgery is the gold standard for therapy of thrombosed external hemorrhoids (TEH).
A prospective cohort study of 72 adults with TEH was conducted: no surgery, no sitz baths but gentle dry cleaning with smooth toilet paper after defecation. Follow-up information was collected six months after admission by questionnaire.
Despite our strict conservative management policy 62.5% (45/72) of patients (95% confidence interval [CI]: 51.0-74.0) described themselves as "healed" or "ameliorated", and 61.1% (44/72, 95% CI: 49.6-72.6) found our management policy as "valuable to test" or "impracticable". 13.9% (10/72, 95% CI: 5.7-22.1) of patients suspected to have recurrences. 4.2% did not know. Twenty-two of the 48 responding patients reported symptoms such as itching (18.8%), soiling (12.5%), pricking (10.4%), or a sore bottom (8.3%) once a month (59.1%, 13/22), once a week (27.3%, 6/22), or every day (13.6%, 3/22).
The dictum that surgery is the gold standard for therapy for TEH should be checked by randomized controlled trials.
This study was a retrospective analysis of complication rates, symptom recurrence, long-term results, and patient satisfaction after outpatient excision (local anesthesia) of thrombosed external hemorrhoids.
From 1995 to 2000, 340 patients (166 males) underwent office-based excision of thrombosed external hemorrhoids under local anesthesia. Data regarding complications, operations because of recurrence, residual symptoms, patient's satisfaction with anesthesia, and wound treatment were obtained by questionnaire. Response was solicited at a minimum of 9 months postprocedure.
Complete follow-up data was available in 88 percent of patients (mean follow-up, 17.3 months). Recurrent thrombosed external hemorrhoid requiring a procedure developed in 22 (6.5 percent) patients. Other complications that required operative intervention were one (0.3 percent) incidence of postoperative bleeding and seven (2.1 percent) perianal abscess/fistula. The majority of patients (66 percent) had no anal complaints at follow-up. Local anesthesia would be preferred if a repeat excision was required in 79 percent, whereas 11 percent would prefer another form of anesthesia and 10 percent were unsure.
Outpatient excision under local anesthesia of a thrombosed external hemorrhoid can be safely performed with a low recurrence and complication rate while offering a high level of patient of acceptance and satisfaction.
Few data exist on the actual recurrence rates of thrombosed external hemorrhoids. We wished to determine the incidence of recurrence, intervals to recurrence, and factors predicting recurrence of thrombosed external hemorrhoids after conservative or surgical management.
Two hundred and thirty-one consecutive patients with thrombosed external hemorrhoids treated from 1990 to 2002 were identified. Recurrence was defined as complete resolution of the index lesion with subsequent return of a thrombosed external hemorrhoid and did not include patients with chronic symptoms. Data were gathered retrospectively. Multiple potential risk factors were reviewed.
The index thrombosed external hemorrhoid was managed conservatively in 51.5 percent of cases and surgically in 48.5 percent. There were no differences between groups in gender, age, or race, and 44.5 percent of all patients had a prior history of thrombosed external hemorrhoid. A prior history was less common in the conservative group than in the surgical group (38.1 percent vs. 51.3 percent; P < 0.05). The frequency of pain or bleeding as the primary complaint was higher in the surgical group ( P < 0.001 and P < 0.002). In addition, the surgical group was more likely to report all three symptoms of pain, bleeding, and a lump ( P < 0.005). Mean follow-up was 7.6 months, with the range extending to 7 years. Time to symptom resolution averaged 24 days in the conservative group vs. 3.9 days in the surgical group ( P < 0.0001). The overall incidence to recurrence was 15.6 percent-80.6 percent in the conservative group vs. 19.4 percent in the surgical group. The rate of recurrence in the conservative group was 25.4 percent (4/29; 14 percent were excised) whereas only 6.3 percent of the surgical patients had recurrence ( P < 0.0001). Mean time to recurrence was 7.1 months in the conservative group vs. 25 months in the surgical group ( P < 0.0001). Survival analysis for time to recurrence of thrombosed external hemorrhoid indicated that time to recurrence was significantly longer for the surgical group ( P < 0.0001). Logistic regression analysis of multiple factors (including diverticular disease, constipation, straining, benign prostatic hypertrophy, diarrhea, skin tags, history of travel, anoreceptive sex, anal fissures, internal hemorrhoids, and obesity) was performed to determine the outcome of each group. None of these variables were significant predictors of recurrence.
Patients whose initial presentation was pain or bleeding with or without a lump were more like to be treated surgically. Surgically treated patients had a lower frequency of recurrence and a longer time interval to recurrence than conservatively treated patients. None of the variables analyzed were significant predictors of a particular treatment, except for a prior history of thrombosed external hemorrhoids, which may represent patient choice. Although most patients treated conservatively will experience resolution of their symptoms, excision of thrombosed external hemorrhoids results in more rapid symptom resolution, lower incidence of recurrence, and longer remission intervals.
Background:
External haemorrhoidal thrombosis (EHT) may be managed surgically or conservatively. The optimal treatment is, however, unclear, as is the long-term outcome following treatment.
Methods:
A literature search was undertaken to review and grade the evidence available for EHT management, determine the optimal management modality and assess long-term outcome after each treatment.
Results:
Among 800 articles on haemorrhoids, only two prospective studies encompassing 248 patients and two retrospective studies of 571 patients were found. Excision significantly relieves presenting symptoms by postoperative day 4 compared with incision or topical GTN (Level IB evidence). Symptoms last over 3 weeks with conservative treatment (Level III evidence) and this period may be reduced by combining topical nifedipine and lignocaine rather than using lignocaine alone (Level IB evidence). There is no evidence regarding the optimal time for non-surgical options.
Conclusions:
There is a remarkable paucity of studies on EHT and few of those available provide high levels of evidence. Surgery may be superior to conservative treatment but there is no evidence regarding the optimal period of initiation of conservative management. Prospective comparative studies are needed.
Outcome measures are helpful in demonstrating patient response to care and therefore an important part of providing best care for our patients. Using paper scoring systems is one way that doctors of chiropractic can document patient progress. This update provides a brief review of the characteristics and applications of the visual analog scale (VAS) and numeric pain scale (NPS).
This study was performed according to a prospective, randomized, open design. The aim was to test the efficacy of local application of nifedipine ointment in healing acute thrombosed external hemorrhoids.
Ninety-eight patients who gave their informed consent were recruited; they received clinical examination and anoscopy. A questionnaire to evaluate symptoms, pain, and concurrent use of analgesics was administered. Patients treated with nifedipine (n = 50) used topical 0.3 percent nifedipine and 1.5 percent lidocaine ointment every 12 hours for two weeks. The control group, consisting of 48 patients, received topical 1.5 percent lidocaine ointment during therapy.
Results obtained were as follows: complete relief of pain in 43 patients (86 percent) of the nifedipine-treated group as opposed to 24 patients (50 percent) of the control group after 7 days of therapy (P < 0.01); oral analgesics were used by 4 patients (8 percent) in the nifedipine-treated group as opposed to 26 patients (54.1 percent) of the control group after 7 days of therapy (P < 0.01); and resolution of acute thrombosed external hemorrhoids was achieved after 14 days of therapy in 46 patients (92 percent) of the nifedipine-treated group, as opposed to 22 patients (45.8 percent) of the control group (P < 0.01). We did not observe any systemic side effect in patients treated with nifedipine.
Our study clearly demonstrates that the use of topical nifedipine, which at present is for treatment of cardiovascular disorders, is a reliable new option in the conservative treatment of thrombosed external hemorrhoids.
Topically applied 0.2% glyceryl trinitrate ointment to the anal region, incision and excision were compared in the treatment of perianal thrombosis, in order to establish which method is the best in terms of pain relief, number of recurrences and the appearance of anal skin tags.
A total of 150 patients were randomly divided into three groups of 50, each group being treated by one of the above-mentioned methods. The results of the treatment were evaluated during the first 4 days, after one month and after one year.
A statistically significant reduction of pain was achieved by excision if compared with incision or conservative treatment with glyceryl trinitrate (p<0.001), and by conservative treatment with glyceryl trinitrate if compared with incision (p<0.01 on the 4th day of follow-up. Comparison of patients treated by the three different methods did not reveal any significant difference between these methods after one month (p>0.05). After one year the number of recurrences was significantly reduced after excision if compared with incision (p<0.05) or conservative treatment with glyceryl trinitrate (p<0.05). The number of patients without symptoms was significantly greater after excision if compared with incision or conservative treatment with glyceryl trinitrate (p<0.001). The number of patients with anal skin tags was significantly reduced in patients treated by excision if compared with incision (p<0.001) or glyceryl trinitrate treatment (p<0.001).
Excision is a significantly better method of treatment of perianal thrombosis than incision or topically applied 0.2% glyceryl trinitrate ointment.
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