The HubBLe Trial: haemorrhoidal artery ligation (HAL) versus rubber band ligation (RBL) for symptomatic second- and third-degree haemorrhoids: a multicentre randomised controlled trial and health-economic evaluation. Treatment of grade III and IV haemorrhoidal disease with PPH or THD. A randomized trial on postoperative complications and short-term results Open versus closed day-case haemorrhoidectomy: is there any difference? Conventional haemorrhoidectomy, stapled haemorrhoidectomy, Doppler guided haemorrhoidectomy artery ligation; post operative pain and anorectal manometric assessment. A validated severity score for haemorrhoids as an essential prerequisite for future haemorrhoid trials Prospective randomised multi-centre trial comparing the clinical efficacy, safety and patient acceptability of circular stapled anopexy with closed diathermy haemorrhoidectomy Does a more extensive mucosal excision prevent haemorrhoidal recurrence after stapled haemorrhoidopexy? Long‐term outcome of a randomized controlled trial Haemorrhoidectomy: Ferguson's (closed) vs Milligan Morgan's technique (open). Stapling procedure for haemorrhoids versus Milligan-Morgan haemorrhoidectomy: randomised controlled trial
 Haemorrhoidal artery ligation versus rubber band ligation for the management of symptomatic second-degree and third-degree haemorrhoids (HubBLe): a multicentre, open-label, randomised controlled trial Stapled versus excision haemorrhoidectomy: long-term follow up of a randomised controlled trial Stapled haemorrhoidectomy in Chinese patients: a prospective randomised control study. How we can improve patients' comfort after Milligan-Morgan open haemorrhoidectomy. Prospective evaluation of stapled haemorrhoidopexy versus transanal haemorrhoidal dearterialisation for stage II and III haemorrhoids: three-year outcomes PPH versus THD: a comparison of two techniques for III and IV degree haemorrhoids. Personal experience. Randomized clinical trial comparing day‐care open haemorrhoidectomy under local versus general anaesthesia Comparison of stapled haemorrhoidopexy with traditional excisional surgery for haemorrhoidal disease (eTHoS): a pragmatic, multicentre, randomised controlled trial
BACKGROUND Optimal surgical intervention for low- grade haemorrhoids is unknown . Rubber b and ligation ( RBL ) is probably the most common intervention . Haemorrhoidal artery ligation ( HAL ) is a novel alternative that may be more efficacious . OBJECTIVE The comparison of HAL with RBL for the treatment of grade II/III haemorrhoids . DESIGN A multicentre , parallel-group r and omised controlled trial . PERSPECTIVE UK NHS and Personal Social Services . SETTING 17 NHS Trusts . PARTICIPANTS Patients aged ≥ 18 years presenting with grade II/III ( second- and third-degree ) haemorrhoids , including those who have undergone previous RBL . INTERVENTIONS HAL with Doppler probe compared with RBL . OUTCOMES Primary outcome - recurrence at 1 year post procedure ; secondary outcomes - recurrence at 6 weeks ; haemorrhoid severity score ; European Quality of Life-5 Dimensions , 5-level version ( EQ-5D-5L ) ; Vaizey incontinence score ; pain assessment ; complications ; and cost-effectiveness . RESULTS A total of 370 participants entered the trial . At 1 year post procedure , 30 % of the HAL group had evidence of recurrence compared with 49 % after RBL [ adjusted odds ratio ( OR ) = 2.23 , 95 % confidence interval ( CI ) 1.42 to 3.51 ; p = 0.0005 ] . The main reason for the difference was the number of extra procedures required to achieve improvement/cure . If a single HAL is compared with multiple RBLs then only 37.5 % recurred in the RBL arm ( adjusted OR 1.35 , 95 % CI 0.85 to 2.15 ; p = 0.20 ) . Persistence of significant symptoms at 6 weeks was lower in both arms than at 1 year ( 9 % HAL and 29 % RBL ) , suggesting significant deterioration in both groups over the year . Symptom score , EQ-5D-5L and Vaizey score improved in both groups compared with baseline , but there was no difference between interventions . Pain was less severe and of shorter duration in the RBL group ; most of the HAL group who had pain had mild to moderate pain , resolving by 3 weeks . Complications were low frequency and not significantly different between groups . It appeared that HAL  was not cost-effective compared with RBL . In the base-case analysis , the difference in mean total costs was £ 1027 higher for  HAL . Quality -adjusted life-years ( QALYs ) were higher for HAL ; however , the difference was very small ( 0.01 ) result ing in an incremental cost-effectiveness ratio of £ 104,427 per additional QALY . CONCLUSIONS At 1 year , although HAL result ed in fewer recurrences , recurrence was similar to repeat RBL . Symptom scores , complications , EQ-5D-5L and continence score were no different , and patients had more pain in the early postoperative period after HAL . HAL is more expensive and unlikely to be cost-effective in terms of incremental cost per QALY . LIMITATIONS Blinding of participants and site staff was not possible . FUTURE WORK The incidence of recurrence may continue to increase with time . Further follow-up would add to the evidence regarding long-term clinical effectiveness and cost-effectiveness . The polysymptomatic nature of haemorrhoidal disease requires a vali date d scoring system , and the data from this trial will allow further assessment of validity of such a system . These data add to the literature regarding treatment of grade II/III haemorrhoids . The results dovetail with results from the eTHoS study [ Watson AJM , Hudson J , Wood J , Kilonzo M , Brown SR , McDonald A , et al. Comparison of  stapled haemorrhoidopexy with traditional excisional surgery  for haemorrhoidal disease ( eTHoS ) : a pragmatic , multicentre , r and omised controlled trial . Lancet 2016 , in press . ] comparing stapled haemorrhoidectomy with excisional haemorrhoidectomy . Combined results will allow expansion of analysis , allowing surgeons to tailor their treatment options to individual patients . TRIAL REGISTRATION Current Controlled Trials IS RCT N41394716 . FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol . 20 , No. 88 . See the NIHR Journals Library website for further project information Purpose Haemorrhoidal disease is a frequently occurring entity in the western world . The Procedure for prolapse and haemorrhoids ( PPH ) and transanal haemorrhoidal dearterialisation ( THD ) are the most important surgical treatments that respect normal anal anatomy . This is the first r and omized trial that compares both techniques in the treatment of grade III and IV haemorrhoids . Methods Patients with grade III or IV haemorrhoids were r and omized between PPH and THD . Patients were seen after 1 week , 3 weeks and 6 weeks postoperatively . Primary endpoint was resolved symptoms 6 weeks postoperatively . Secondary endpoints were pain , measured with a visual analogue scale ( VAS ) after 1 day , 1 week and 3 weeks , and complications Results Eighteen patients were allocated to PPH versus 23 to THD . Success rates after 6 weeks were 83 % in the PPH group versus 78 % in the THD group . VAS scores were significantly lower after 1 day and 1 week in the THD group , but equalled out after 3 weeks . Twelve percent of the patients after PPH and 4 % after THD needed an urgent readmission to treat an acute bleeding . Overall complication rates did not differ significantly . Conclusion Both PPH and THD are safe treatments for grade III and IV haemorrhoids with acceptable complication rates and good short-term results . THD might be the preferred treatment because it carries the similar complication rate and short-term results , but results in less postoperative pain when compared with PPH . Moreover , it is a less invasive , more easily learned and less costly procedure Background and aims Nowadays there is still controversy as to whether open or closed haemorrhoidectomy is the surgical treatment of choice for haemorrhoidal pathology . Patients and methods We carried out a r and omised prospect i ve study in the Day Surgery Unit comparing 100 patients undergoing Milligan-Morgan haemorrhoidectomy ( group A ) versus 100 patients undergoing Ferguson haemorrhoidectomy ( group B ) for symptomatic haemorrhoids , in whom medical treatment or rubber b and ligation had failed . Results Characteristics of the population were : mean age 43.5 years , with predominance of males , 123 vs. 77 ; 88 % ASA I-II . Clinical presentation : 95 % rectal bleeding ; 87.5 % third-fourth degree . The anaesthetic technique of choice was local anaesthesia plus sedation in 180 patients ( 90 % ) . Length of surgery : 24 min ( group A ) and 30 min ( group B ) ( p = n.s . ) . Resection of three haemorrhoidal cushions was done in 87.5 % of cases . There were no re-operations or re-admissions after discharge . Symptomatic recurrence , stenosis and incontinence were not found during the follow-up of the first year . Postoperative pain during the first postoperative week was greater in the open haemorrhoidectomy group , but the difference was statistically significant ( p<0.05 ) only during bowel movements . There was complete healing in 40 % of the patients in group A and 90 % of those in group B ( p<0.05 ) after 1 month . After 1 year , the results and complications were similar in both groups ( p = n.s . ) . Conclusions Closed haemorrhoidectomy gives better results in terms of pain and healing than open haemorrhoidectomy , whereas recurrence and complications are similar after 1 year BACKGROUND / AIMS The aim of the present article was to compare stapled haemorrhoidectomy , and haemorrhoidal artery ligation with open haemorrhoidectomy with respect to the postoperative pain , symptom control , and manometric alterations . METHODOLOGY Forty five patients with third or fourth-degree haemorrhoids were r and omly classified into three groups ; first group managed by stapled haemorrhoidectomy , second group managed by conventional haemorrhoidectomy and third group managed by Doppler guided haemorrhoidal artery ligation . ( 15 patients each ) Preoperative and 12 weeks postoperative anorectal manometry were done for all patients . RESULTS There was a significant difference of the operative time between stapled group and  Milligan-Morgan  group ( p < 0.001 ) while no significant difference between stapled group and Doppler group . The pain scores were significantly higher in open group ( p < 0.001 ) during the first 24 hours at the time of first motion and one week after operation . Postoperative control of prolapsed symptoms was significantly better with open diathermy haemorrhoidectomy than with stapled . The control of other symptoms was similar with regard to bleeding , pain , pruritus , and incontinence scores . Anorectal manometry showed a decrease in the maximum resting pressure and maximum squeeze pressure in all groups , but this decrease was only significant in the stapled haemorrhoidectomy group . CONCLUSIONS Stapled and Doppler haemorrhoidectomy is as effective as conventional haemorrhoidectomy for the treatment of haemorrhoids , but with the exception of skin tag prolapse . There is a need for long-term follow-up for the changes in manometric parameters after haemorrhoidectomy Background There is a lack of st and ardised outcomes for haemorrhoidal disease making comparison between trials difficult . A need for a very well vali date d severity score is essential to facilitate meta- analysis of comparative studies , enabling evidence -based clinical practice . Methods The Hubble trial provides a large cohort of patients with haemorrhoidal disease r and omised to rubber b and ligation ( RBL ) or haemorrhoidal artery ligation .  The  haemorrhoid severity score ( HSS )  was collected on each patient at baseline , 6 weeks and 1 year after intervention . This allows for the responsiveness of the HSS instrument to be examined and compared with a more specific instrument , the Vaizey incontinence score ( also collected ) . Responsiveness was tested using four methods ( effect size , st and ardised response means ( SRM ) , significance of change , and responsiveness statistic ) . Results The four tests of responsiveness demonstrated that the HSS was more responsive to changes in the patient ’s health status following both of the interventions compared to the Vaizey question naire . For example , between baseline and 6 weeks , the RBL intervention effect size scores and SRM calculations indicated a non-significant small amount of change ( 0.20 and 0.16 respectively ) . However , using the HSS , the effect size and SRM demonstrated a large magnitude of change ( 1.12 and 1.01 , respectively ) which was significant . Similar results were observed at 1 year . Significance of change scores and the index of responsiveness were also higher for the HSS question naire than the Vaizey across both treatment modalities . Conclusions The HSS is a highly responsive tool for the detection of changes in haemorrhoid symptoms . It should form an essential patient-reported outcome tool for future studies on haemorrhoidal disease Objective : Unlike excisional haemorrhoidectomy , stapled anopexy ( SA ) , which does not involve radical excision , has theoretical advantages , thus offering potential patient benefits . We compared the clinical efficacy , safety and patient acceptability of SA , with closed haemorrhoidectomy ( CH ) . Patients and methods : 182 patients with symptomatic haemorrhoids ( grade s II , III , IV ) were r and omly assigned to receive SA or  CH  and were followed for up to 1 year ( 6 , 12 , 24 , 48 weeks ) after operation . Postoperative pain , symptom control , complications , re-treatment rates , patient satisfaction , and quality of life were compared on an intention-to-treat basis . Results : Postoperative pain in the SA group ( n = 91 ) was significantly lower ( p = 0.004 , Mann – Whitney U test ) . At 1 year there were no significant differences in the symptom load , symptom severity or the disease severity between the two groups . Overall complication rates were similar but faecal urgency was reported more frequently following SA ( p = 0.093 , Fisher ’s exact test ) . Despite a similar rate of residual symptoms , prolapse control was better with CH ( p = 0.087 , Fisher ’s exact test ) , and more patients in the SA group required re-treatment for residual prolapse at 1 year ( p = 0.037 , Fisher ’s exact test ) . However , more patients rated SA as an excellent operation at 6 and 12 weeks ( p = 0.008 and 0.033 , binary logistic regression ) and were willing to undergo a repeat procedure if required ( p = 0.018 , Fisher ’s exact test ) . Conclusion : Stapled anopexy offers a significantly less painful alternative to excisional haemorrhoidectomy and achieves a higher patient acceptability . Although the overall symptom control and safety are similar in the majority of the patients , the re-treatment rate for recurrent prolapse at 1 year is higher following SA when compared to CH AIM The study aim ed in a multicentric r and omized controlled trial to define the role of a more extensive mucosal resection on recurrence of mucosal prolapse in patients with Stage III haemorrhoids undergoing stapled haemorrhoidopexy .  METHOD In all , 135 patients were r and omized to treatment with a PPH-01/03 ( Ethicon EndoSurgery ) or an EEA ( Covidien ) stapler .  They were review ed after a minimum follow-up of 4 years to determine the rate of recurrent mucosal prolapse and general condition ( wellness evaluation score ) . Postoperative bowel dysfunction was assessed using the Rome III criteria . RESULTS Eighty-seven ( 65 % ) of the 135 patients ( 48 in the EEA stapler group and 37 in the PPH group ) were available for long-term follow-up . The two groups were comparable for age , gender and duration of follow-up ( mean 49.3 ± 5.4 months and 49.0 ± 5.3 months respectively ) . In the EEA group , 11 ( 23 % ) patients had some degree of recurrent prolapse compared with 12 ( 32 % ) in the PPH group ( P = 0.409 ) . Persistence of anal bleeding was significantly higher in the PPH group ( P = 0.04 ) while the postoperative Haemorrhoid Symptom Score was significantly better in the EEA group ( 1.73 ± 1.65 vs 3.17 ± 1.94 , P < 0.001 ) . The wellness evaluation score was significantly better in the EEA group ( 1.2 ± 1.27 vs 0.6 ± 1.0 , P = 0.028 ) . Furthermore , 7 ( 15 % ) of the patients in the EEA group complained of some evacuation disturbance compared with 13 ( 36 % ) in the PPH group ( P = 0.021 ) . CONCLUSION The study failed to demonstrate any significant difference in the long-term recurrence rate of Stage III haemorrhoids using EEA or PPH . Nevertheless , use of the larger volume EEA provides better symptom resolution compared with PPH This study was done to compare the efficacy of closed Vs open haemorrhoidectomy . The study design was unblinded r and omised control trial at Dhulikhel Hospital , Kathm and u University Hospital . Total number of patients was 56 all with 3rd and 4th degree haemorrhoids . Post operative pain was taken as main outcome measures . Operation time varied from 200 seconds for each haemorroidal cushion with open technique to 626 seconds by closed technique . The blood loss was not quantifiable in closed technique . Pain was scored on visual analogue scale . In closed group , the pain score was 4.9 immediate post operative period and 2.3 ( 24 hours later ) . In the other group , the scores were 7.8 and 6.9 . These differences were significant . At the end of study we came to a conclusion that haemorrhoidectomy using closed technique has more advantages BACKGROUND Surgical haemorrhoidectomy has a reputation for being a painful procedure for a fairly benign disorder . The circular transanal stapled technique for the treatment of haemorrhoids has the potential to offer a less painful rectal procedure in place of ablative perianal surgery . We compared the short-term outcome of the circular stapled procedure for haemorrhoids with current st and ard surgery in a r and omised controlled trial . METHODS 40 patients admitted for surgical treatment of prolapsing haemorrhoids were r and omly assigned to Milligan-Morgan haemorrhoidectomy ( n=20 ) or the circular stapled procedure . Under general anaesthesia patients underwent st and ardised diathermy excision haemorrhoidectomy or had a circumferential doughnut of rectal mucosa and submucosa above the dentate line excised and closed with a st and ard circular end-to-end stapling device . All patients received st and ardised preoperative and postoperative analgesic and laxative regimens . Patients completed linear analogue pain charts each day and were interviewed at 1 , 3 , and 6 - 10 weeks postoperatively . Summary measures of average pain experience were calculated from 10 cm linear analogue pain scores and were used as the primary outcome measure . FINDINGS The stapled group had shorter anaesthesia time ( median 18 [ range 9 - 25 ] vs 22 [ 15 - 35 ] mins ) . Average pain in the stapled group was significantly lower than it was in the Milligan-Morgan group ( 2.1 [ 0.2 - 7.6 ] vs 6.5 [ 3.1 - 8.5 ] , 95.1 % CI difference medians 1.9 - 4.7 , p<0.0001 . Mann-Whitney U test ) . Average pain relative to what the patient expected was also significantly less in the stapled group ( -2.8 [ -4.4 to 1.3 ] vs 0.7 [ -1.8 to 3.4 ] . Hospital stay and time to first bowel motion were not significantly different between groups . Return to normal activity was significantly shorter in the stapled group ( 17 [ 3 - 60 ] vs 34 [ 14 - 90 ] . Early and late complications , patient-assessed symptom control , and functional outcome appear similar after short-term follow-up . INTERPRETATION The circular stapled technique offers a significantly less painful alternative to Milligan-Morgan haemorrhoidectomy and is associated with an earlier return to normal activity . Early symptom control and functional outcome appear similar . However , long-term symptomatic and functional outcome need further study Summary Background Optimum surgical intervention for low- grade haemorrhoids is unknown . Haemorrhoidal artery ligation ( HAL ) has been proposed as an efficacious , safe therapy while rubber b and ligation ( RBL ) is a commonly used outpatient treatment . We compared recurrence after HAL versus RBL in patients with grade II – III haemorrhoids . Methods This multicentre , open-label , parallel group , r and omised controlled trial included patients from 17 acute UK NHS trusts . We screened patients aged 18 years or older presenting with grade II – III haemorrhoids . We excluded patients who had previously received any haemorrhoid surgery , more than one injection treatment for haemorrhoids , or more than one RBL procedure within 3 years before recruitment . Eligible patients were r and omly assigned ( in a 1:1 ratio ) to either RBL or HAL with Doppler . R and omisation was computer-generated and stratified by centre with blocks of r and om sizes . Allocation concealment was achieved using a web-based system . The study was open-label with no masking of participants , clinicians , or research staff . The primary outcome was recurrence at 1 year , derived from the patient 's self-reported assessment in combination with re source use from their general practitioner and hospital records . Recurrence was analysed in patients who had undergone one of the interventions and been followed up for at least 1 year . This study is registered with the IS RCT N registry , IS RCT N41394716 . Findings From Sept 9 , 2012 , to May 6 , 2014 , of 969 patients screened , 185 were r and omly assigned to the HAL group and 187 to the RBL group . Of these participants , 337 had primary outcome data ( 176 in the RBL group and 161 in the HAL group ) . At 1 year post-procedure , 87 ( 49 % ) of 176 patients in the RBL group and 48 ( 30 % ) of 161 patients in the HAL group had haemorrhoid recurrence ( adjusted odds ratio [ aOR ] 2·23 , 95 % CI 1·42–3·51 ; p=0·0005 ) . The main reason for this difference was the number of extra procedures required to achieve improvement ( 57 [ 32 % ] participants in the RBL group and 23 [ 14 % ] participants in the HAL group had a subsequent procedure for haemorrhoids ) . The mean pain 1 day after procedure was 3·4 ( SD 2·8 ) in the RBL group and 4·6 ( 2·8 ) in the HAL group ( difference −1·2 , 95 % CI −1·8 to −0·5 ; p=0·0002 ) ; at day 7 the scores were 1·6 ( 2·3 ) in the RBL group and 3·1 ( 2·4 ) in the HAL group ( difference −1·5 , −2·0 to −1·0 ; p<0·0001 ) . Pain scores did not differ between groups at 21 days and 6 weeks . 15 individuals reported serious adverse events requiring hospital admission . One patient in the RBL group had a pre-existing rectal tumour . Of the remaining 14 serious adverse events , 12 ( 7 % ) were among participants treated with HAL and two ( 1 % ) were in those treated with RBL . Six patients had pain ( one treated with RBL , five treated with HAL ) , three had bleeding not requiring transfusion ( one treated with RBL , two treated with HAL ) , two in the HAL group had urinary retention , two in the HAL group had vasovagal upset , and one in the HAL group had possible sepsis ( treated with antibiotics ) . Interpretation Although recurrence after HAL was lower than a single RBL , HAL was more painful  than RBL . The difference in recurrence was due to the need for repeat b and ings in the RBL group . Patients ( and health commissioners ) might prefer such a course of RBL to the more invasive HAL . Funding NIHR Health Technology Assessment programme Advantages of the stapling procedure for haemorrhoids  include reduced postoperative pain and shortened convalescence ; however , there are few data with respect to functional and symptomatic outcome . At a dedicated clinic , we review ed patients between Dec , 2001 , and March , 2002 , who had taken part in a r and omised controlled trial undertaken at the unit in 1999 , which compared outcomes after open or stapled haemorrhoidectomy .  We noted the presence or absence of haemorrhoid specific symptoms , and assessed overall satisfaction , continence , and quality of life .  Rigid sigmoidoscopy and an anorectal examination were also used to examine symptomatic recurrence and disease activity . At minimum follow-up of 33 months since surgery , both techniques seem to be equally effective OBJECTIVE To compare stapled haemorrhoidectomy with open diathermy haemorrhoidectomy in Chinese patients with respect to the  postoperative pain , symptom control , and manometric alterations .  DESIGN Prospect i ve r and omised controlled trial . SETTING A regional general surgical unit , Hong Kong . PATIENTS Twenty-four patients with second- or third-degree haemorrhoids or who have had failed medical treatment . INTERVENTION Open diathermy haemorrhoidectomy or stapled haemorrhoidectomy . MAIN OUTCOME MEASURES Structured question naire for symptoms , anorectal manometry , transrectal ultrasound , and postoperative pain . RESULTS Stapled haemorrhoidectomy compared with open diathermy haemorrhoidectomy result ed in similar postoperative pain and drug requirements . Postoperative control of prolapse symptoms was significantly better with open diathermy haemorrhoidectomy than with stapled . The control of other symptoms was similar with regard to bleeding , pain , pruritus , and incontinence scores . Anorectal manometry showed a decrease in the maximum resting pressure and maximum squeeze pressure in both groups , but the decrease was only significant in the stapled haemorrhoidectomy group . CONCLUSIONS Stapled haemorrhoidectomy is as effective as conventional haemorrhoidectomy for the treatment of haemorrhoids , but with the exception of skin tag prolapse . There is a need for long-term follow-up for the changes in manometric parameters after haemorrhoidectomy AIM To demonstrate the value of Diosmin ( flavonidic fraction ) in the management of post-haemorhoidectomic symptoms . METHODS Eighty-six consecutive patients with grade s III and IV acute mixed hemorrhoids admitted to the Anorectal Surgical Department of First Affiliated Hospital , Xinjiang Medical University from April 2009 to April 2010 , were enrolled in this study . An observer-blinded , r and omized trial was conducted to compare post-haemorhoidectomic symptoms with use of Diosmin flavonidic fraction vs placebo .  Eighty-six patients were r and omly allocated to receive Diosmin flavonidic fraction 500 mg for 1 wk ( n = 43 ) or placebo ( n = 43 ) . The Milligan-Morgan open haemorrhoidectomy was performed by a st and ardized diathermy excision method . Pain , bleeding , heaviness , pruritus , wound edema and mucosal discharge were observed after surgery . The postoperative symptoms and hospitalization time were recorded . RESULTS The mean age of the Diosmin group and controls was 53.2 and 51.3 years , respectively . In Diosmin group , haemorrhoid piles were of the third degree in 33 patients and the fourth degree in 10 ; and in the control group , 29 were of the third degree and 14 were of the fourth degree . There was no statistically significance in age , gender distribution , degree and number of excised haemorrhoid piles , and the mean duration of haemorrhoidal disease between the two groups . There was a statistically significant improvement in pain , heaviness , bleeding , pruritus from baseline to the 8th week after operation ( P < 0.05 ) . Patients taking Diosmin had a shorter hospitalization stay after surgery ( P < 0.05 ) . There was also a significant improvement on the proctoscopic appearance ( P < 0.001 ) . However , there was no statistical difference between the two groups in terms of wound mucosal discharge . Two patients experienced minor bleeding at the 8th week in Diosmin group , and underwent surgery . CONCLUSION Diosmin is effective in alleviating postoperational symptoms of haemorrhoids . Therefore , it should be considered for the initial treatment after haemorrhoid surgery . However , further prospect i ve r and omized trials are needed to confirm the findings of this study Introduction The aim of the study was to compare short- and medium-term outcomes of transanal haemorrhoidal dearterialisation ( THD ) versus stapled haemorrhoidopexy ( SH ) for the treatment of second- and third-degree haemorrhoids . Methods Patients with second- or third-degree haemorrhoids who failed conservative treatment were r and omly allocated to THD or SH .  Preoperative and postoperative symptoms , postoperative pain , time until return to normal activities , complications , patient satisfaction and recurrence rates were all assessed prospect ively . Patients were followed up at 2 , 8 months and when the study was completed . Results Twenty-eight patients ( 43 % third degree ) underwent THD and 24 ( 38 % third degree ) underwent SH . There were no significant differences in terms of postoperative pain , expected pain and analgesia requirements , but more THD patients returned to work within 4 days ( P < 0.05 ) . One THD patient developed a sub-mucosal haematoma after surgery , one SH patient occlusion of the rectal lumen and two rectal bleeding . At 8-month follow-up , two SH patients complained of faecal urgency . At 38-month follow-up ( range 33–48 months ) , all short-term complications resolved . Patient satisfaction ( “ excellent/good outcome ” , THD 89 vs. SH 87 % ) and recurrence rate ( THD 14 vs. SH 13 % ) were similar in the two groups . Conclusions Short-term results although similar seem to suggest SH may result in increased morbidity while return to work is quicker after THD . Medium-term results demonstrate that THD and SH have similar effectiveness AIM The aim of our study was to evaluate , through prospect i ve r and omized study , the outcome and the immediate and late complications of the two types of surgery most widely used for degree III-IV haemorrhoids . METHODS A total of 122 patients with degree III and IV hemorrhoids were elected for surgical intervention and , r and omly , underwent  surgery for PPH or THD . We assessed the most common immediate postoperative complications . The patients have been followed for three months with a mean follow-up at 1 month and 3 months after surgery . Parameters taken into consideration were : bleeding , pain at rest and after evacuation , soiling , constipation and tenesmus . RESULTS Five patients in PPH group ( 7.9 % ) had a major postoperative bleeding , whereas no such episode occurred in THD group ( P = ns ) . In percentage terms , VAS score was lower in THD group than in PPH group , although the difference was not statistically significant . Finally parameters values observed , during the follow-up , proved to be lower for THD group compared to PPH group . CONCLUSION PPH and THD are two surgical treatments for degree III and IV haemorrhoids with low perioperative complications and good results in the short term . However , our experience shows that better results in terms of pain and fewer postoperative complications are obtained after THD surgery , such surgery is less invasive and more adaptable to the needs of day surgery Day‐care open haemorrhoidectomy under local anaesthesia ( LH ) may be the most cost‐effective approach to haemorrhoidectomy . This prospect i ve r and omized trial compared outcome after LH  from patients ' and clinical perspectives with that after day‐care open haemorrhoidectomy under general anaesthesia ( GH ) Summary Background Two commonly performed surgical interventions are available for severe ( grade II – IV ) haemorrhoids ;  traditional excisional surgery and stapled haemorrhoidopexy . Uncertainty exists as to which is most effective . The eTHoS trial was design ed to establish the clinical effectiveness and cost-effectiveness of stapled haemorrhoidopexy compared with traditional excisional surgery . Methods The eTHoS trial was a large , open-label , multicentre , parallel-group , pragmatic r and omised controlled trial done in adult participants ( aged 18 years or older ) referred to hospital for surgical treatment for grade II – IV haemorrhoids . Participants were r and omly assigned ( 1:1 ) to receive either traditional excisional surgery or stapled haemorrhoidopexy . R and omisation was minimised according to baseline EuroQol 5 dimensions 3 level score ( EQ-5D-3L ) , haemorrhoid grade , sex , and centre with an automated system to stapled haemorrhoidopexy or traditional excisional surgery . The primary outcome was area under the quality of life curve ( AUC ) measured with the EQ-5D-3L descriptive system over 24 months , assessed according to the r and omised groups . The primary outcome measure was analysed using linear regression with adjustment for the minimisation variables . This trial is registered with the IS RCT N registry , number IS RCT N80061723 . Findings Between Jan 13 , 2011 , and Aug 1 , 2014 , 777 patients were r and omised ( 389 to receive  stapled haemorrhoidopexy and 388 to receive  traditional excisional surgery ) . Stapled haemorrhoidopexy was less painful  than traditional excisional surgery in the short term and surgical complication rates were similar between groups . The EQ-5D-3L AUC score was higher in the traditional excisional surgery group than the stapled haemorrhoidopexy group over 24 months ; mean difference −0·073 ( 95 % CI −0·140 to −0·006 ; p=0·0342 ) . EQ-5D-3L was higher for stapled haemorrhoidopexy in the first 6 weeks after surgery , the traditional excisional surgery group had significantly better quality of life scores than the stapled haemorrhoidopexy group . 24 ( 7 % ) of 338 participants who received stapled haemorrhoidopexy and 33 ( 9 % ) of 352 participants who received traditional excisional surgery  had serious adverse events . Interpretation As part of a tailored management plan for haemorrhoids , traditional excisional surgery should be considered over stapled haemorrhoidopexy as the surgical treatment of choice . Funding National Institute for Health Research Health Technology Assessment programme
Scores values tended to decrease postoperatively .
The comparison between haemorrhoidal treatments is still unclear .
Attempts have been made to adopt a unifying postoperative scoring system and thus ensure adequate comparison between clinical trials .
We aim ed to systematic ally review the available outcome scores of haemorrhoidal treatment .