title: Ligation anopexy versus hemorrhoidectomy in the treatment of second- and third-degree hemorrhoids Reporting of patient-reported outcomes in randomized trials: the CONSORT PRO extension. Randomized clinical trial of symptom control after stapled anopexy or diathermy excision for haemorrhoid prolapse Does a more extensive mucosal excision prevent haemorrhoidal recurrence after stapled haemorrhoidopexy? Long‐term outcome of a randomized controlled trial Prospective randomised multi-centre trial comparing the clinical efficacy, safety and patient acceptability of circular stapled anopexy with closed diathermy haemorrhoidectomy Comparison of stapled haemorrhoidopexy with traditional excisional surgery for haemorrhoidal disease (eTHoS): a pragmatic, multicentre, randomised controlled trial Prospective evaluation of stapled haemorrhoidopexy versus transanal haemorrhoidal dearterialisation for stage II and III haemorrhoids: three-year outcomes Embolization of the Superior Rectal Arteries for Hemorrhoidal Disease: Prospective Results in 25 Patients. Randomized controlled trial comparing rubber band ligation with stapled haemorrhoidopexy for Grade II circumferential haemorrhoids: long‐term results The prevalence of hemorrhoids in adults Long‐term results of stapled haemorrhoidopexy in a prospective single centre study of 153 patients with 1–6 years’ follow‐up Transanal haemorrhoidal dearterialization (THD) for selected fourth-degree haemorrhoids Perianal Local Block for Stapled Anopexy Stapled and Open Hemorrhoidectomy: Randomized Controlled Trial of Early Results 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. Minimal open hemorrhoidectomy A validated severity score for haemorrhoids as an essential prerequisite for future haemorrhoid trials Doppler-guided transanal haemorrhoidal dearterialization for haemorrhoids: results from a multicentre trial.
abstract: Abstract Background The aim of the study was to compare ligation anopexy ( LA ) and conventional hemorrhoidectomy ( CH ) in treatment of second- and third-degree hemorrhoids . Methods A prospect i ve controlled r and omized clinical trial included 100 patients who underwent CH ( CH group ) and 100 patients who underwent LA ( LA group ) . A detailed history was taken from all the patients . The effectiveness , safety , postoperative complications , operative time , length of hospital stay , time until first bowel movement , time until return to work , and postoperative pain score were assessed . Results There was no significant difference between groups regarding age , sex , and preoperative symptoms . The LA group had significantly shorter operative times , earlier first bowel movement , and an earlier return to work/activities . The postoperative pain score in the LA group was significantly lower than that in the CH group on days 1 , 3 , 7 , and 14 after surgery . There was no significant difference between groups as regards postoperative complications . Conclusions LA is safe , and as effective as CH in the treatment of grade II and grade III hemorrhoids , with shorter operative times , earlier mobilization , and lower postoperative pain scores The CONSORT ( Consoli date d St and ards of Reporting Trials ) Statement aims to improve the reporting of r and omized controlled trials ( RCTs ) ; however , it lacks guidance on the reporting of patient-reported outcomes ( PROs ) , which are often inadequately reported in trials , thus limiting the value of these data . In this article , we describe the development of the CONSORT PRO extension based on the method ological framework for guideline development proposed by the Enhancing the Quality and Transparency of Health Research ( EQUATOR ) Network . Five CONSORT PRO checklist items are recommended for RCTs in which PROs are primary or important secondary end points . These recommendations urge that the PROs be identified as a primary or secondary outcome in the abstract , that a description of the hypothesis of the PROs and relevant domains be provided ( ie , if a multidimensional PRO tool has been used ) , that evidence of the PRO instrument 's validity and reliability be provided or cited , that the statistical approaches for dealing with missing data be explicitly stated , and that PRO-specific limitations of study findings and generalizability of results to other population s and clinical practice be discussed . Examples and an up date d CONSORT flow diagram with PRO items are provided . It is recommended that the CONSORT PRO guidance supplement the st and ard CONSORT guidelines for reporting RCTs with PROs as primary or secondary outcomes . Improved reporting of PRO data should facilitate robust interpretation of the results from RCTs and inform patient care This multicentre r and omized clinical trial studied how symptoms improved after either stapled anopexy or diathermy excision of haemorrhoids 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 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 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 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 PURPOSE To evaluate efficacy and safety of superior rectal artery embolization of hemorrhoidal disease as a first-line invasive treatment . MATERIAL S AND METHODS This prospect i ve study was conducted between 2014 and 2015 on 25 consecutive patients ( 16 men and 9 women with a mean age of 53 y [ range , 30 - 76 y ] ) with grade II-III hemorrhoids refractory to medical treatment . A transfemoral superselective superior rectal artery branch embolization was performed using 2- and 3-mm diameter microcoils . Over the following 12 months , clinical outcomes were evaluated using the French bleeding score , Goligher prolapse score , visual analog scale ( VAS ) score for pain , quality -of-life score . The primary endpoint was relief of symptoms by 12 months based on a 2-point minimum improvement on VAS score and bleeding score . RESULTS At 12 months after embolization , clinical success was obtained in 18 patients ( 72 % ) , 8 of whom had 2 embolizations . VAS score decreased from 4.6 to 2.3 ( P < .01 ) , and bleeding score decreased from 5.5 to 2.3 ( P < .01 ) . Quality -of-life and prolapse scores also showed improvement ( P < .05 ) , and no patients experienced any early or late complications . Complete clinical failure was observed in 7 patients . After coil embolization , the collateral supply to the hemorrhoidal cushions was significantly related to any recurrence ( P = .001 ) . CONCLUSIONS Hemorrhoidal artery coil embolization was found to be a safe and effective treatment for grade II-III hemorrhoids Objective An improved underst and ing of the pathophysiology of haemorrhoids has result ed in the introduction of new surgical techniques including stapled haemorrhoidopexy ( SH ) . This r and omized controlled trial compared the long‐term effectiveness of SH with rubber b and ligation ( RBL ) in the treatment of grade II circumferential symptomatic haemorrhoids Introduction Exact data on the prevalence of hemorrhoids are rare . Therefore , we design ed a study to investigate the prevalence of hemorrhoids and associated risk factors in an adult general population . Methods Between 2008 and 2009 , consecutive patients were included in a prospect i ve study . They attended the Austrian national wide health care program for colorectal cancer screening at four medical institutions . A flexible colonoscopy and detailed examination were conducted in all patients . Hemorrhoids were defined according to a st and ardized grading system . Independent variables included baseline characteristics , sociodemographic data , and health status . Potential risk factors were calculated by univariate and multivariate analysis . Results Of 976 participants , 380 patients ( 38.93 % ) suffered from hemorrhoids . In 277 patients ( 72.89 % ) , hemorrhoids were classified as grade I , in 70 patients ( 18.42 % ) as grade II , in 31 patients ( 8.16 % ) as grade III , and in 2 patients ( 0.53 % ) as grade IV . One hundred seventy patients ( 44.74 % ) complained about symptoms associated with hemorrhoids , whereas 210 patients ( 55.26 % ) reported no symptoms . In the univariate and multivariate analysis , body mass index ( BMI ) had a significant effect on the occurrence of hemorrhoids with p = 0.0391 and p = 0.0282 , respectively . Even when correcting for other potential risk factors , an increase in the BMI of one increased the risk of hemorrhoids by 3.5 % . Conclusion Hemorrhoids occur frequently in the adult general population . Notably , a considerable number of people with hemorrhoids do not complain about symptoms . In addition , a high BMI can be regarded as an independent risk factor for hemorrhoids Aim The long‐term results of stapled haemorrhoidopexy for prolapsed haemorrhoids were assessed using uniform methods to acquire data and pre‐set definitions of failure , recurrence , residual symptoms and impaired continence Background Traditional treatment of fourth-degree haemorrhoidal disease ( HD ) is conventional haemorrhoidectomy and is frequently associated with significant pain and morbidity . In recent years , the use of transanal haemorrhoidal dearterialization ( THD ) for the treatment of HD has increased . The procedure aims to decrease the arterial blood flow to the haemorrhoids . Moreover , since a rectal mucopexy to treat the prolapsing component has become part of the THD technique , this treatment is also indicated for more advanced HD . The aim of this study was to assess the possible role of THD in the treatment of fourth-degree HD . Methods All patients with non-fibrotic fourth-degree HD were offered the THD procedure with mucopexy . Excision of skin tags was added to THD and mucopexy , when needed . A specific score was used to assess HD severity , ranging from 0 ( no HD ) to 20 ( worst HD ) . The mean preoperative score was 18.1 ± 1.8 . Results Thirty-five consecutive patients ( mean age 50.4 ± 13.8 years ; 19 men ) with fourth-degree HD were prospect ively enroled . An average of 6 arteries were identified and transfixed . Mucopexy was achieved with a 3–6 sector plication of rectal mucosa . Mean operating time was 33 ± 12 min . No intraoperative complications were recorded . Postoperative morbidity included 3 ( 8.6 % ) haemorrhoidal thromboses ( 1 requiring surgery ) and 2 ( 5.7 % ) episodes of bleeding ( 1 requiring surgical haemostasis ) . Five patients ( 14.3 % ) had urinary retention requiring catheterization . At a median follow-up of 10 months ( range 2–28 months ) , symptoms had resolved or significantly improved in 33 ( 94 % ) patients . Nine patients ( 25.7 % ) reported irregular bleeding , 3 patients ( 8.6 % ) mild anal pain , 4 patients ( 11.4 % ) transient anal burning and 4 patients ( 11.4 % ) tenesmus . Ten patients ( 28.6 % ) experienced some degree of residual prolapse , significant only in 2 ( 5.7 % ) who required further surgery . There was no anorectal stenosis , and no faecal incontinence was reported . At a median follow-up of 10 months , the symptomatic score was 2.5 ± 2.5 ( P < 0.005 ) . Conclusion Transanal haemorrhoidal dearterialization seems to be a safe and effective treatment for fourth-degree HD providing a significant improvement of symptoms for the majority of patients . When present , persisting symptoms are mostly transient , occasional or limited in severity , and only a very few patients require further intervention . Larger series and longer follow-up to further assess the role of THD in this challenging group of pts Purpose This study was design ed to demonstrate the usefulness of a method of regional anesthesia for circular stapler anopexy for prolapsing hemorrhoids . Methods Thirty-three patients consented to stapled anopexy under perianal local anesthesia . Eighteen patients with stapled anopexy under general anesthesia were controls . The perianal block was applied with 40 ml of ropivacaine , 4.75 mg/ml , injected immediately peripheral to the external sphincter . A submucosal block with 15 ml of ropivacaine , 2 mg/ml , was added after applying the pursestring suture .  Postoperative pain was rated by the patient for 14 days by using a ten-point visual analogue scale . Patients also su bmi tted a preoperative and postoperative ( 3–6 months ) symptom question naire to rate anal symptoms . Results No operation was converted to general anesthesia . Operation time was similar in both groups . All patients in the local anesthesia group were pain free at discharge . The sums of pain scores during 14 days for daily average pain and peak pain were similar in both groups ( average pain 23 ( local anesthesia ) vs. 35 ( general anesthesia ) ; peak pain 39 ( local anesthesia ) vs. 50 ( general anesthesia ) ; P > 0.05 ) . The preoperative symptom scores were 7.8 ( local anesthesia ) vs. 8.9 ( general anesthesia ) points , and the follow-up scores were 2.2 ( local anesthesia ) and 2.7 ( general anesthesia ) , a significant improvement ( P = 0.001 ) in both groups but not different between groups . Conclusions A perianal local block is easy to apply and has a high degree of acceptance among patients . The operation time , postoperative pain , and success rates of the operation equaled those of stapled anopexy performed under general anesthesia . The advantages are quicker turnover between cases and simpler management of pain-free postoperative patients in day surgery The aim of the study was to compare the early results in 52 patients r and omly allocated to undergo either stapled or open hemorrhoidectomy . Seventy-four patients with grade III and IV hemorrhoids were r and omly allocated to undergo either stapled ( 37 patients ) or open ( 37 patients ) hemorrhoidectomy . Stapled hemorrhoidectomy was performed with the use of a circular stapling device . Open hemorrhoidectomy was accomplished according to the Milligan-Morgan technique . Postoperative pain was assessed by means of a visual analogue scale ( V.A.S. ) . Recovery evaluation included return to pain-free defecation and normal activities . A 6-month clinical follow-up and a 17.5 ( 10 to 27)-month median telephone follow-up was obtained in all patients . Operation time for stapled hemorrhoidectomy was shorter ( median 25 [ range 15 to 49 ] minutes versus 30 [ range 20 to 44 ] minutes , p = 0.041 ) . Median ( range ) V.A.S. scores in the stapled group were significantly lower ( V.A.S. score after 4 hours : 4 [ 2 to 6 ] versus 5 [ 2 to 8 ] , p = 0.001 ; V.A.S. score after 24 hours : 3 [ 1 to 6 ] versus 5 [ 3 to 7 ] , p = 0.000 ; V.A.S. score after first defecation : 5 [ 3 to 8 ] versus 7 [ 3 to 9 ] , p = 0.000 ) . Resumption of pain-free defecation was significantly faster in the stapled group ( 10 [ 6 to 14 ] days vs 12 [ 9 to 19 ] days , p = 0.001 ) . At follow-up 4 weeks and 6 months postoperatively the median ( range ) symptom severity score was similar in both groups ( 1 [ 0 to 2 ] versus 0 [ 0 to 3 ] , p = 0.150 and 0 [ 0 to 2 ] versus 0 [ 0 to 2 ] , p = 0.731 ) . At long-term follow-up occasional pain was present in 6/37 ( 16.2 ) patients in the stapled group and 7/37 ( 18.9 % ) in the Milligan-Morgan group ( p = 1.000 ) ; episodes of bleeding were reported by 8/37 ( 21.6 % ) patients in the stapled group and 5/37 ( 13.5 % ) patients in the Milligan-Morgan group ( p = 0.542 ) . No problems related to continence and defecation were reported in either group . Patients were satisfied with the operation in 33/37 ( 89.2 % ) cases in the stapled group and 31/37 ( 83.8 % ) cases in the Milligan-Morgan group ( p = 0.735 ) . Hemorrhoidectomy with a circular staple device is easy to perform and achieves better results than the Milligan-Morgan technique in terms of postoperative pain and recovery . Comparable results are obtained at long-term follow-up 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 The original operation for  open hemorrhoidectomy  as described by Milligan – Morgan is no longer used . There is a great variation in how the operation is described in clinical trials . A number of modifications have been proposed attempting to reduce postoperative pain . An anatomical plane for the dissection was first described by Loder and Phillips [ 1 ] . They encountered small fibers passing from the internal sphincter to the anal cushions and emphasized the importance of dividing these fibers close to the cushions leaving an intact surface over the internal sphincter . Gerjy et al. described a subdermal fascia continuing into a membrane covering the internal sphincter , which was easily identified after incision of the skin of the pedicle [ 2 ] . In addition , Loder and Phillips were the first to suggest diathermy dissection and coagulation [ 1 ] . A better knowledge of hemorrhoidal vascular anatomy , demonstrating , how the arterial supply to the hemorrhoids crosses the rectal wall , has reduced the need for pedicle ligation . Seow-Chonen et al. demonstrated in a r and omized study that diathermy dissection , when compared to scissor dissection , result ed in less postoperative pain and Bessa et al. showed how diathermy coagulation of the pedicle was superior to ligation in reducing postoperative pain [ 3 , 4 ] . We adapted these principles and also minimized excision of the skin and the hemorrhoid . In addition , we left a part of the hemorrhoid intra-anally to reduce any impact on anal continence . We called this modification “ minimal open hemorrhoidectomy ” ( MOH ) . Material s and 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 AIM This multicentre study , based on the largest patient population ever published , aims to evaluate the efficacy of Doppler-guided transanal haemorrhoidal dearterialization ( THD Doppler ) in the treatment of symptomatic haemorrhoids and to identify the factors predicting failure for an effective mid-term outcome . METHOD Eight hundred and three patients affected by Grade II ( 137 , 17.1 % ) , III ( 548 , 68.2 % ) and IV ( 118 , 14.7 % ) symptomatic haemorrhoidal disease underwent THD Doppler , with a rectal mucopexy in patients with haemorrhoidal prolapse . The disease was assessed through a specifically design ed symptom question naire and scoring system . A uni- and multivariate analyses of the potential predictive factors for failure were performed . RESULTS The morbidity rate was 18.0 % , represented mainly by pain or tenesmus ( 106 patients , 13.0 % ) . Acute bleeding requiring surgical haemostasis occurred in seven patients ( 0.9 % ) . No serious or life-threatening complications occurred . After a mean follow-up period of 11.1 ± 9.2 months , the overall success rate was 90.7 % ( 728 patients ) , with a recurrence of haemorrhoidal prolapse , bleeding , and both symptoms in 51 ( 6.3 % ) , 19 ( 2.4 % ) and 5 ( 0.6 % ) patients , respectively . Sixteen out of 47 patients undergoing re-operation had a conventional haemorrhoidectomy . All the symptoms were significantly improved in each domain of the score ( P < 0.0001 ) . At multivariate analysis the absence of morbidity and performance of a distal Doppler-guided dearterialization were associated with a better outcome . CONCLUSION THD Doppler is a safe and effective therapy for haemorrhoidal disease . If this technique is to be employed , an accurate distal Doppler-guided dearterialization and a tailored mucopexy are m and atory to contain and reduce the symptoms
target: Scores values tended to decrease postoperatively .
background: 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 .