Visiting Fellow Papers

Abstract

Purpose/Background: The search for the best treatment for hemorrhoids is ongoing. Patients tend to choose less effective but less invasive treatments, whereas most surgical trials report effectiveness as the most important end-point. Intrahemorrhoidal laser, or laser hemorrhoidoplasty (LHP), was first described in 2009. Our own experience suggested this method to be minimally invasive, safe and effective procedure for symptomatic hemorrhoids. Doppler-guided hemorrhoidal artery ligation was compared to non-Doppler guided ligation – rectoanal repair (RAR) – in the randomized trial, with the latter being more effective in controlling prolapse after 6 months observation and significantly reducing cost of the procedure. Excisional hemorrhoidectomy (EH) is the most effective treatment with long and well documented history. The aim of this study was to identify factors, which are associated with perfect (10 out of 10) evaluation on visual analogue scale by the patients at the end of 1 year of follow-up of double-blind randomized trial. Methods/Interventions: This is a randomized, parallel group doubleblinded single centre prospective study. Patients with symptomatic 2nd or 3rd degree hemorrhoids, in 1st or 2nd risk group of ASA, who consented to participate in this study were included into the study. Detailed physical examination was performed with anoscopy and rigid proctoscopy in all cases. All patients filled a dedicated symptom questionnaire, which included questions on intensity and frequency of hemorrhoidal prolapse, bleeding, itching, pain and other symptoms. Every patient completed Wexner incontinence score, SF-36 and FIQOL questionnaires. The patients were randomized into three groups: LHP, RAR and EH. Computer based randomization sequence, patient blinding throughout the study, surgeon blinding preoperatively and surgeon-evaluator blinding postoperatively were used to reduce bias. LHP was performed using Ceralas diode laser of 1420 nm wavelength (Biolitec). Disposable LHP kit (Biolitec) was used, which contains sharp-tipped laser fiber and anoscope. Perianal skin immediately aboral to hemorrhoid was penetrated using needle-tip cautery. Laser fiber was introduced into the opening until the level of hemorrhoidal pedicle and coagulation was activated. 8 Watt 3 second pulses with 1 second pulsepauses were used to coagulate the area of hemorrhoids. 5 mm of hemorrhoidal tissue is coagulated with one such pulse. 250 Joules was the upper limit of energy delivered per 1 hemorrhoidal quadrant. Smaller hemorrhoids were treated with less energy. The procedure was repeated in three other quadrants, thus treating all anal circumference. RAR was performed as described by Schurmann JP. For these patients, the ligations were placed in the area of visible pathologic hemorrhoidal tissue, and in patients with large prolapse mucopexy – lifting of prolapsing hemorrhoidal tissue with sutures was performed. Standard EH was performed up to the level of hemorrhoidal pedicle, with ligation or suture-ligation of the pedicle and meticulous hemostasis. Each patient was followed up at 1 and 6 weeks and after 1 year after the operation with perianal examination, anoscopy (at 6 weeks and 1 year), symptom questionnaires (at 1 and 6 weeks and 1 year), Wexner incontinence score, FIQOL and SF-36 (at 1 year). Sample size calculation was performed using R statistical software package (©The R Foundation). Presuming the effect size of 0.3, power of 0.8 and alpha = 0.05 the sample size was calculated to be 108 patients. To compensate for possible follow-up losses sample size was increased to 120 patients. Chi-square test and Anova tests were used to compare differences between the groups. Univariate analysis was performed to identify factors, which were associated with perfect evaluation of operation by the patients (10 out of 10 on visual analogue scale at 1-year follow-up visit) and stepwise multivariate linear logistic regression was performed to identify factors independently associated with the perfect evaluation by the patient. Results/Outcome(s): One hundred and twenty one patients were included into the study: 40 into LHP group, 40 into EH group and 41 into RAR group from April 2016 to April 2017. One-year follow-up was completed in April 2018. All included patients participated in the scheduled visits and completed the follow-up as required per protocol. 52 patients rated their operation 0–9 and 69 patients rated their operation 10 on their follow-up visit. No recurrence of symptoms, less time to return to work and LHP were associated with increased possibility of perfect evaluation of the operation on univariate analysis. Conclusions/Discussion: Laser hemorrhoidoplasty and no recurrence of symptoms are independently associated with increased possibility of perfect evaluation of operation by the patients at one-year follow-up. JSCP Fellow Operative procedure contributes to decreased male sexual dysfunction after surgery for mid to low rectal cancer Y. Nishizawa, A. Kondo, Y. Tsukada, T. Sasaki, M. Inoue, H. Masuda & M. Ito Department of Colorectal Surgery, National Cancer Center Hospital East, Department of Urology, National Cancer Center Hospital East