Prospective randomised multi-centre trial comparing the clinical efficacy, safety and patient acceptability of circular stapled anopexy with closed diathermy haemorrhoidectomy. How we can improve patients' comfort after Milligan-Morgan open haemorrhoidectomy. Prospective randomized controlled trial of a micronized flavonidic fraction to reduce bleeding after haemorrhoidectomy. Clinical use of micronized purified flavonoid fraction for treatment of symptoms after hemorrhoidectomy: results of a randomized, controlled, clinical trial. Prospective randomized multicentre trial comparing stapled with open haemorrhoidectomy. Flavonoids to reduce bleeding and pain after stapled hemorrhoidopexy: a randomized controlled trial. Randomized clinical trial of micronized flavonoids in the early control of bleeding from acute internal haemorrhoids. Long-term results after excision haemorrhoidectomy versus stapled haemorrhoidopexy for prolapsing haemorrhoids; a Belgian prospective randomized trial. Randomised trial comparing LigaSure haemorrhoidectomy with the diathermy dissection operation. Randomized clinical trial of Ligasure versus conventional diathermy for day-case haemorrhoidectomy. Circumferential mucosectomy (stapled haemorrhoidectomy) versus conventional haemorrhoidectomy: randomised controlled trial. Randomized multicentre trial of the influence of recombinant human erythropoietin on intraoperative and postoperative transfusion need in anaemic patients undergoing right hemicolectomy for carcinoma. Randomized comparison between stapled hemorrhoidopexy and Ferguson hemorrhoidectomy for grade III hemorrhoids in Taiwan: a prospective study. [Treatment of acute symptoms of hemorrhoid disease with high-dose oral O-(beta-hydroxyethyl)-rutosides]. Prospective, randomized, controlled, observer-blinded trial of combined infrared photocoagulation and micronized purified flavonoid fraction versus each alone for the treatment of hemorrhoidal disease. The treatment of second degree haemorrhoids by injection, rubber band ligation, maximal anal dilatation, and haemorrhoidectomy: a prospective clinical trial. A randomised comparison of medical and hysteroscopic management in women consulting a gynaecologist for treatment of heavy menstrual loss.
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).
                182 patients with symptomatic haemorrhoids (grades II, III, IV) were randomly 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.
                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).
                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. To demonstrate the value of Diosmin (flavonidic fraction) in the management of post-haemorhoidectomic symptoms.
                Eighty-six consecutive patients with grades 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, randomized trial was conducted to compare post-haemorhoidectomic symptoms with use of Diosmin flavonidic fraction vs placebo. Eighty-six patients were randomly 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 standardized diathermy excision method. Pain, bleeding, heaviness, pruritus, wound edema and mucosal discharge were observed after surgery. The postoperative symptoms and hospitalization time were recorded.
                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.
                Diosmin is effective in alleviating postoperational symptoms of haemorrhoids. Therefore, it should be considered for the initial treatment after haemorrhoid surgery. However, further prospective randomized trials are needed to confirm the findings of this study. A prospective randomized controlled trial was carried out on the effects of Daflon 500 mg (a micronized flavonidic fraction containing diosmin 450 mg and hesperidin 50 mg) on bleeding after haemorrhoidectomy. In all, 228 consecutive patients with prolapsed irreducible piles were recruited. Elective haemorrhoidectomy was performed with a standardized diathermy excision method. Some 114 patients were randomized to receive Daflon 500 mg for 1 week after operation (group 1), and there were 114 controls (group 2). Postoperative analgesia and laxative prescription as well as hospital stay were otherwise the same. One patient (0.9 per cent) from group 1 and seven (6.1 per cent) from group 2 had postoperative bleeding (P = 0.03). All bleeding occurred from 6 to 15 days after haemorrhoidectomy. There were no side-effects from the use of Daflon 500 mg. The risk of secondary bleeding from haemorrhoidectomy is reduced with postoperative Daflon. The aim of this study was to evaluate if the combination of micronized purified flavonoid fraction with short-term routine antibiotic and anti-inflammatory therapy was better at reducing the intensity of postoperative symptoms and wound bleeding after a Milligan-Morgan's open hemorrhoidectomy than antibiotic and anti-inflammatory treatment alone.
                Fifty patients were randomly assigned to receive routine antibiotic and anti-inflammatory treatment alone (control patients) or a combination of micronized purified flavonoid fraction with identical antibiotic and anti-inflammatory treatment (micronized purified flavonoid fraction patients). The evolution of symptoms (pain, tenesmus, pruritus, and bleeding) during the postoperative period was assessed by means of patients' self-questionnaires. Each symptom was scored on a graded severity scale from 0 to 3, daily during the first three days of the immediate postoperative period, then at regular intervals (about every 14 days) until postoperative day 60. A global score for evaluation of each postoperative symptom and bleeding was used. The global score for each symptom was the sum of scores for each patient over the study period. The global score for each symptom was compared between the two groups with the Mann-Whitney U test.
                No significant differences in age, gender distribution, and stage of disease between the two groups were noticed at baseline. Posthemorrhoidectomy symptoms were relieved more rapidly in the micronized purified flavonoid fraction group; during the first three postoperative days, the global score for each symptom was significantly more reduced in the micronized purified flavonoid fraction group. The global scores for each symptom are as follows: pain after 3 days, 6.16 (SD = 1.9) in the control group vs. 3.48 (SD = 1.8) in the micronized purified flavonoid fraction group (P < 0.0001); tenesmus, 5.36 (SD = 1.8) in the control group vs. 1.48 (SD = 1.5) in the micronized purified flavonoid fraction group (P < 0.0001); pruritus, 4.04 (SD = 1.9) in the control group vs. 1.84 (SD = 1.4) in the micronized purified flavonoid fraction group (P < 0.0001); bleeding, 4.4 (SD = 2.1) in the control group vs. 2.0 (SD = 1.3) in the micronized purified flavonoid fraction group (P < 0.0001). A significant difference (P < 0.0001) between groups was also shown in favor of micronized purified flavonoid fraction patients when global scores were calculated over the entire study period (60 days).
                Micronized purified flavonoid fraction used in combination with short-term antibiotic and anti-inflammatory treatment can reduce both the duration and extent of postoperative symptoms and wound bleeding following hemorrhoidectomy. The aim of this study was to compare the results of conventional open haemorrhoidectomy as currently practised in Italy (group 1) with stapled haemorrhoidectomy using a 33-mm circular stapling device (group 2).
                One hundred patients with symptomatic third- and fourth-degree haemorrhoids were enrolled by five hospitals. Patients were allocated to the two groups according to a centralized randomization scheme featuring five permutated blocks of 20. Preoperative clinical examination and anorectal manometry demonstrated no features of anal incontinence. Patients had a clinical and manometric re-evaluation after operation and were asked to complete a clinical diary. After a median of 16 (range 8-19) months patients were administered a standardized questionnaire by telephone.
                Postoperative bleeding requiring haemostatic procedures occurred in three patients in each group. Patients in group 1 complained of moderate pain for a median of 5.3 (range 0-19) days compared with 3.1 (range 0-10) days in group 2 (P = 0.01), while severe pain was present for 2.3 (range 0-24) days in group 1 but only for 1 (range 0-14) day in group 2 (P = 0.03). The median hospital stay was 2 days in group 1 compared with 1 day in group 2 (P = 0.01). In the early days after operation, patients in group 2 had greater difficulty in maintaining normal continence to liquid stools (P = 0.01), but after 30 days the continence score was better in group 2 (P = 0.04).
                Stapled haemorrhoidectomy is as effective as conventional haemorrhoidectomy. Reduced postoperative pain, shorter hospital stay and a trend toward earlier return to work suggest short-term advantages for the stapled technique. Control of postoperative symptoms is of paramount importance in ambulatory surgery. This trial was conducted to evaluate whether a micronized purified flavonoid fraction (MPFF) (Detralex((R))) reduces postoperative bleeding, pain and consumption of analgesics after ambulatory stapled hemorrhoidopexy, as reported in trials after classic hemorrhoidectomy. Phlebotropic activity, protective effect on the capillaries and anti-inflammatory properties of this drug have been reported in several studies.
                Sixty-three patients with third-degree hemorrhoids had ambulatory stapled hemorrhoidopexy under spinal anesthesia in the period of one year. The patients were randomized, with 30 receiving Detralex 500 mg (2 tablets 3 times daily for 5 days after the operation) and 33 forming the control group. The patients were asked to daily self-assess the presence of blood on defecation, degree of pain and consumption of analgesics for the first week after the operation.
                There was no significant difference between the two groups in duration of presence of blood, degree of pain or analgesics requirement. No major complications, such as bleeding requiring transfusion or hospitalization, sepsis, anal stenosis or urgent defecation, were noted in the follow-up period. There were no side effects from Detralex treatment.
                In our study we could not demonstrate any positive effect of prescribing flavonoids after stapler hemorrhoidopexy. This procedure may not be sufficiently aggressive and is associated with too few postoperative complications to show any protective influence of flavonoids. Patients with acute bleeding from internal haemorrhoids often have to be referred by the general practitioner to the surgeon for definitive treatment with invasive outpatient procedures. At the initial consultation, patients frequently seek postponement of immediate surgery to a more convenient time. Effective and rapid non-invasive control of acute bleeding could be of practical use in scheduling surgery to a time convenient to both patient and surgeon.
                In a 90-day randomized, double-blind study treatment with a micronized purified flavonoid fraction (MPFF) was compared with placebo, in 100 outpatients who presented for treatment of acute internal haemorrhoids of less than 3 days' duration. The primary endpoint was cessation of bleeding on the third day of treatment.
                Of 50 patients randomized to each group, acute bleeding ceased by the third day in 40 (80 per cent) who received MPFF compared with 19 (38 per cent) who had placebo (P < 0.01). Mean(s.d. ) duration of acute bleeding from onset to cessation of 4.9(1.6) days was 2.1 (95 per cent confidence interval 1.2-2.9) days less than that in patients receiving placebo (P < 0.01). Continued treatment in patients with no bleeding prevented a relapse in 30 of 47 patients, compared with 12 of 30 receiving placebo (P < 0.05).
                Patients with acute internal haemorrhoids treated with MPFF had rapid cessation of bleeding and a reduced risk of relapse. This could be of value in the more convenient timing of treatment with invasive outpatient procedures. To compare the postoperative evolution and the long-term efficacy after stapled haemorrhoidopexy (PPH) and Milligan-Morgan haemorrhoidectomy (MM).
                In a prospective randomized study, 40 patients requiring surgical treatment for prolapsing haemorrhoids grade II or III were assigned to either MM or PPH (20 each). Postoperative pain, wound healing were evaluated, as well as anal pressures and sphincter anatomy. Mean follow-up is 46 months.
                Postoperative pain at rest and during defecation was less important after PPH if no resection of external piles or skin tags was associated (P < 0.0001). Healing time was shorter after PPH (P < 0.0001). Endoanal ultrasound remained unchanged postoperatively. Resting and squeeze pressures decreased after MM, but not after PPH (P < 0.01). After a mean follow-up of 46 months (12-56), persistent or recurrent symptoms, mostly mild and temporary, were observed after both MM and PPH, in 7 and 11 patients respectively (NS). After PPH, five patients (25%) complained of recurrent external swelling and/or prolapse (P = 0.047 vs. MM) requiring redo surgery in four of them, after 10, 13, 14 and 21 months. No redo-surgery was required after MM. Long term patient satisfaction after PPH was not better than after MM.
                Postoperative pain is less important after PPH. This advantage disappears if any resection is associated with the stapling. At medium to long-term follow-up, PPH seems to carry a higher risk of symptomatic external haemorrhoidal disease, needing further surgery. The study was designed to compare LigaSure haemorrhoidectomy with open haemorrhoidectomy performed by means of diathermy excision. Fifty-sixty consecutive patients with third- and fourth-degree haemorrhoids were randomly allocated to undergo either LigaSure haemorrhoidectomy (29 patients) or diathermy haemorrhoidectomy (27 patients). All patients were evaluated for operative time, pain, post-operative analgesic requirements, time to first bowel movement, length of hospital stay, wound healing period, time to return to work, and occurrence of early postoperative complications (such as urinary dysfunction, bleeding, soiling, seepage, continence disorders) and late complications (such as stenosis). A statistically significant advantage was observed in the patients who received the LigaSure technique as far as concerns length of operative time (9.2 vs. 12.2 min, p<0.001), post-operative analgesic requirements (14.1 vs. 16.8 administrations, p<0.001), wound healing period (16.3 vs. 37.5 days, p< 0.0001), and time to return to work (8.3 vs. 18.3 days, p<0.01). No significant difference was seen in the postoperative pain score, complications rate, first bowel motion or hospital stay. No recurrence was observed at the 6-month follow-up. In conclusion, our experience shows that the LigaSure haemorrhoidectomy offers definite advantages over the classic diathermy technique. This procedure is easier, safer, and more rapid to perform and is followed by a faster wound healing time, a significantly shorter hospital stay, less postoperative pain and faster wound healing. Haemorrhoidectomy is frequently associated with postoperative pain and prolonged hospital stay. A new technique of haemorrhoidectomy using the Ligasure device suited to day-case surgery is described. This technique was compared with conventional open diathermy haemorrhoidectomy.
                Forty patients with grade III or IV haemorrhoids were randomized to Ligasure (group 1) or conventional diathermy (group 2) haemorrhoidectomy. Operative details were recorded and patients recorded daily pain scores on a linear analogue scale. Follow-up was at 1, 3, 6 and 12 weeks to evaluate complications, return to normal activity, ongoing symptoms and patient satisfaction.
                Reduced intraoperative blood loss (median (range) 0 (0-5) ml versus 20 (12-22) ml; P < 0.001) and a shorter operating time (10 (8-11) versus 20 (18-25) min; P < 0.001) was observed in group 1 compared with group 2. More patients in group 1 were discharged on the day of operation (18 of 20 versus 11 of 20; P < 0.05) and there was a trend towards lower postoperative pain scores on day 1 (group 1 median 5 (95 per cent confidence interval (c.i.) 2.6 to 6.8) versus group 2 7 (95 per cent c.i. 4.2 to 7.7); P = 0.36). There was no difference between the two groups in the degree of patient satisfaction or number of postoperative complications.
                Ligasure diathermy may be used safely in the treatment of patients with grade III or IV haemorrhoids. It reduces intraoperative blood loss and operating time, and facilitates same-day discharge. Haemorrhoidectomy is commonly an inpatient procedure because it is frequently associated with postoperative pain. Day case haemorrhoidectomy is a similar operation to that used on inpatients but with different strategies for managing postoperative pain. Circumferential mucosectomy (stapled haemorrhoidectomy) may be associated with less postoperative pain than conventional haemorrhoidectomy. We compared stapled haemorrhoidectomy with conventional haemorrhoidectomy in patients with third degree haemorrhoids.
                We randomly assigned 22 patients to conventional haemorrhoidectomy by the diathermy dissection or to stapled haemorrhoidectomy with the use of an intraluminal stapling device. Patients were discharged when free of pain, took co-codamol as required, completed visual analogue charts each day, and were assessed at 1 and 6 weeks postoperatively for symptom control.
                All patients received the assigned treatment. Mean inpatient stay was lower in the group assigned to stapled as opposed to conventional haemorrhoidectomy (1.09 [0.3] vs 2.82 [0.09] nights, p<0.001), experienced less pain overall (p=0.003), and returned to normal activities sooner (8.1 [1.53] vs 16.9 [2.33] days, p<0.005). Stapled haemorrhoidectomy controlled symptoms of prolapse, discharge and bleeding in all patients.
                Stapled haemorrhoidectomy is an effective treatment for third degree haemorrhoids with significant advantages for patients compared with conventional haemorrhoidectomy. The possible immunosuppressive effect of blood transfusion and its influence on survival after surgery for cancer makes it worthwhile to seek methods to avoid transfusion wherever possible. Patients with right-sided colonic cancer are frequently anaemic. Such patients were entered into a study that employed erythropoietin to avoid homologous transfusion.
                In a prospectively randomized double-blind placebo-controlled multicentre trial, patients with moderate anaemia (haemoglobin concentration greater than 8.5 g/dl and less than or equal to 13.5 g/dl) presenting with right-sided colonic cancer and scheduled for hemicolectomy were treated with recombinant human erythropoietin (epoetin beta) 20,000 units/day subcutaneously or placebo for at least 10 days over the operative period.
                Perioperative treatment with epoetin beta was well tolerated and there were no significant differences in morbidity and mortality. Following hemicolectomy, median cumulative blood loss in the two groups was similar (epoetin beta 440 ml versus placebo 345 ml). Sixteen (33 per cent) of 48 patients treated with epoetin beta and 15 (28 per cent) of 54 in the placebo group received perioperative blood transfusions (P not significant). The increase in reticulocyte count between baseline and the last preoperative value was more pronounced in the epoetin beta group than in those receiving placebo (P = 0.036).
                Despite the perioperative administration of 20,000 units erythropoietin per day for at least 10 days, it was not possible to reduce the intraoperative and postoperative transfusion need. None the less, a positive change in the haematological variables of treated patients was clearly discernible. The negative result may be due to the short treatment interval and to iron deficiency, which was present in the majority of patients. The general change of attitude towards allogeneic blood transfusion is demonstrated by the overall low frequency of blood transfusion in this study. Short-term and mid-term outcomes of stapled hemorrhoidopexy (SH) were compared with those for Ferguson hemorrhoidectomy (FH) for treating hemorrhoids.
                Patients with prolapsed hemorrhoids were randomized into two groups treated with SH (N = 300) and FH (N = 296) at Chang Gung Memorial Hospital at Chiayi in Taiwan between January 2002 and December 2004. The outcomes of the procedures were evaluated postoperatively (short-term, i.e., intra-/postoperative conditions, hospital stay, pain intensity scoring, time off work, and procedure-related morbidity) and over a follow-up period of minimum 18 months (mid-term, i.e., relapse of prolapse and/or bleeding, anal stricture, anal sepsis, and the acceptability of the procedures to the patients).
                SH was superior to FH in operative time, intraoperative blood loss, postoperative pain intensity, and return to work. Based on telephone interviews over the follow-up period, most patients who received SH appreciated the procedure better than those with FH.
                This study confirms that SH generates less postoperative suffering, less time off work, and more complete resolution of primary symptoms associated with hemorrhoids in the mid-term follow-up than FH. The pharmacological treatment is widely used in the therapy of haemorrhoids. An efficient treatment is particularly useful in case of haemorrhoids of 2nd, 3rd and 4th degree, when phlogosis, oedema and pain are present. Forty patients were treated with either O-(beta-hydroxyethyl)-rutosides (4 g/day orally) or placebo in a double blind randomized comparative trial. The groups of treatment were homogeneous. O-(beta-hydroxyethyl)-rutosides induced a statistically significant reduction of pain and bleeding; placebo did not induce any significant improvement. Tolerability was good and similar for both treatments. It has never been necessary to stop treatment for side effects. The results obtained in this study confirm the usefulness on administering an oral treatment, and not only a local treatment, to patients with acute symptoms of haemorrhoids, both in case of intermittent treatment and in case it is used to prepare quickly the patient for surgery. Infrared photocoagulation (IRP) is commonly used in the treatment of hemorrhoids, but rectal bleeding can persist after this procedure. Adjuvant therapy may thus be considered for more definitive control of symptoms, particularly bleeding.
                The goal of this study was to compare the efficacy of a treatment combining IRP and oral micronized purified flavonoid fraction (MPFF) versus each treatment used alone on bleeding cessation in patients with grades I, II, and III acute internal hemorrhoids.
                This was a prospective, randomized, controlled, single-blind study. Consecutive outpatients were randomly assigned to a treatment combining MPFF and IRP or to each treatment separately. For each patient, bleeding status was reported at day 0 (day of inclusion) and compared with that at day 5 after treatment by observers blinded to treatment assignment. Follow-up visits were planned at days 7, 30, 60, and 90 of therapy, including monitoring of treatment-related side effects and self-reporting by patients of any problem related to hemorrhoidal disease.
                A total of 351 patients (180 women, 171 men) were enrolled in the study. Their mean age was 49.2 years (range, 29-71 years). Hemorrhoids were grade I in 33.6% (118 patients), grade II in 48.7% (171 patients), and grade III in 17.7% (62 patients) of the study population. Patients were randomly assigned to each of the 3 treatment groups (117 patients in each), with no significant difference between groups in the age, sex, or distribution of grade of hemorrhoids. The percentage of patients with no bleeding after 5 days of treatment was higher in the combined treatment group (74.8%) compared with MPFF alone (59.6%; P = 0.023) or with IRP alone (55.6%; P = 0.004). MPFF alone was as effective as IRP alone at stopping bleeding. Patients with grades I and II hemorrhoids responded significantly better (82.5% and 61.7%, respectively) to either treatment than those with grade III hemorrhoids (22.9%; P < 0.001). Of the 216 patients who were followed up for 90 days, 3 had a gastrointestinal adverse event, and 19 had a relapse of bleeding.
                Five days of treatment combining MPFF with IRP significantly reduced bleeding status in these study patients with grades I and II acute internal hemorrhoids compared with each treatment used alone. One hundred and twenty patients with confirmed second degree haemorrhoids were randomly allocated to four treatment groups; injection, rubber band ligation, maximal anal dilatation, and haemorrhoidectomy. Each groups consisted of 30 patients. All patients were regularly followed up for at least one year. Assessment at one year showed that haemorrhoidectomy "cured" the haemorrhoids in 29 out of 30 patients. Rubber band ligation relieved 25 out of 30 and maximal anal dilatation 24 out of 30. Injection was the least effective treatment, and relieved 18 of the 30 patients, with a cure rate of 60% only. Haemorrhoidectomy caused pain in all cases, anal stenosis in two, postoperative haemorrhage in two, and the patients required an average hospital stay of 11.5 days and an average of a further 15.5 days off work. Rubber band ligation was painless in 26 patients out of 30, and maximal anal dilatation was painless in 25 our of 30. There were no postoperative complications in the latter two treatment groups. Haemorrhoidectomy is good in "curing" the disease, but the higher possibility of postoperative pain and complications and longer hospital stay would not justify its use in the treatment of second degree haemorrhoids. Both rubber band ligation and maximal anal dilatation are effective and relatively free from complications. Rubber band ligation has the additional advantage of not requiring hospital stay or anaesthesia and is therefore considered to be the most appropriate method of treatment for second degree haemorrhoids. To compare medical with hysteroscopic management in women referred to a gynaecologist complaining of heavy menstrual loss.
                Single-centre randomised trial.
                A teaching hospital in the United Kingdom.
                One hundred and ninety-seven women seeking specialist treatment of heavy menstrual loss for the first time and willing to accept either treatment.
                1. Medical treatments not previously used by the women prescribed by experienced gynaecologists in standard doses and timings for a minimum of three cycles (n = 94), and 2. transcervical resection of the endometrium performed under general anaesthesia five weeks after goserelin preparation (n = 93).
                Treatment satisfaction and acceptability, relief of symptoms, change in haemoglobin, and improvement in health related quality of life, all after four months.
                Women allocated transcervical resection were more likely to be totally or generally satisfied (76% versus 27%, P < 0.001), to find the treatment acceptable (93% versus 36%, P < 0.001), and willing to have the treatment again (93% versus 31%, P < 0.001). Although pain and bleeding were significantly reduced by medical treatment this was modest in comparison with transcervical resection (P < 0.001). Haemoglobin levels were significantly increased only following transcervical resection. Short form 36 scores were also improved in both arms, although only transcervical resection returned them to normal values.
                Medical treatment was less effective than transcervical resection of the endometrium, irrespective of previous treatment or type of medical management. Early hysteroscopic endometrial surgery should be considered by such woman with the choice made by the woman after a full discussion of the advantages and disadvantages of all the options.
The evidence suggests that there is a potential benefit in using phlebotonics in treating haemorrhoidal disease as well as a benefit in alleviating post-haemorrhoidectomy symptoms. Outcomes such as bleeding and overall symptom improvement show a statistically significant beneficial effect and there were few concerns regarding their overall safety from the evidence presented in the clinical trials.
However methodological limitations were encountered. In order to enhance our conclusion further, more robust clinical trials which take into account these limitations will need to be performed in the future.