| Keywords [eng] |
Haemorrhoids, management, surgical, conservative, rubber band ligation, sclerotherapy, anal dilation, excisional haemorrhoidectomy, (EH), stapled haemorrhiodopexy, doppler-guided haemorrhoidal artery ligation with recto-anal repair (DG-HAL RAR), anorectal. |
| Abstract [eng] |
BACKGROUND: Haemorrhoids can be defined as the symptomatic engorging or displacement of the anal cushions [1,2]. Across the world, haemorrhoids still remain one of the most prevalent diseases of the anorectal area, contributing to significant morbidity due to poor symptom control. In determining the appropriateness of treatment modality, several factors, including the degree of prolapse and severity of symptoms are taken into account, as well as patients’ age and pre-existing comorbidities. OBJECTIVES: This study aimed to identify currently studied treatment options for symptomatic haemorrhoids; highlight the drawbacks as well as advantages of each treatment modality based on the randomised controlled trials (RCTs), and, thirdly, to provide recommendations based on research. METHODS: A comprehensive PubMed search was conducted to identify Randomised Controlled Trials which compared various treatment methods for haemorrhoidal prolapse. Several inclusion and exclusion criteria were applied to the search results, and the data from the trials eligible for inclusion was subsequently analysed. A Cochrane Risk of Bias assessment was conducted on the available studies to assess the quality of evidence. RESULTS: 87 Randomised Controlled Studies were included in this review with a total of 9493 participants. The techniques analysed were Stapled hemorrhoidopexy, Transanal Haemorrhoidal dearterialisation (THD), Laser haemorrhoidoplasty, Hemorrhoidal artery ligation (HAL), Radiofrequency, Mucopexy, Lord’s (anal dilation), Rubber Band Ligation, Milligan-Morgan (the ‘open’) haemorrhoidectomy, Ferguson (the ‘closed’) haemorrhoidectomy, Milligan-Morgan with Ligasure, Milligan-Morgan with Harmonic Scalpel, and Park’s haemorrhoidectomies. In total, 31 randomised controlled studies contained good quality evidence, 52 studies carried some concerns, and 4 studies had a high risk of bias. CONCLUSION: The decision to treat haemorrhoids (of any degree), whether non-invasively or invasively, lies mainly with patients’ presenting complaints, such as pain on evacuation and the extent of morbidity in day-to-day activities. For symptomatic low grade haemorrhoids, as well as the advanced prolapse, lifestyle and diet modifications form the important foundation of the management strategy, and are prescribed as the initial step in the management. If not sufficient alone, minimally invasive techniques, such as radiofrequency ablation can be tried first, as they offer promising results with reduced pain scores and fast return to daily activities. As recurrence rates, however, are higher with these techniques compared to traditional haemorrhoidectomy, some patients may experience relapses and need re-operating on. The data extracted from the trials suggests Stapled haemorrhoidopexy to be a highly efficient technique for grades 3 and 4 haemorrhoids, with reduced pain scores,shorter hospital stays, reduced healing times and return to normal activities, and overall high patient satisfaction. Alternatively, laser haemorrhoidoplasty delivers similar satisfactory results, is associated with lower pain scores and accelerated return to normal activities. However, evidence suggests that these techniques are associated with significantly higher recurrence rates, compared to excisional haemorrhoidectomy. From the available data, Milligan-Morgan procedure accounts for longer operative times, higher pain scores, increased healing times and delayed return to normal activities,. However, this technique, especially when facilitated by LigaSure sealing device or Harmonic Scalpel, has the lowest recurrence rates and still remains the gold standard for managing haemorrhoids of advanced degree (especially 4th degree). |
