Techniques in Coloproctology (2020) 24:145–164

https://doi.org/10.1007/s10151-020-02149-1

REVIEW

Consensus statement of the Italian society of colorectal surgery

(SICCR): management and treatment of hemorrhoidal disease
G. Gallo1,2 · J. Martellucci3 · A. Sturiale4 · G. Clerico2 · G. Milito5 · F. Marino6 · G. Cocorullo7 · P. Giordano8 ·
M. Mistrangelo9 · M. Trompetto2 

Received: 28 October 2019 / Accepted: 6 January 2020 / Published online: 28 January 2020
© The Author(s) 2020

Abstract
Hemorrhoidal disease (HD) is the most common proctological disease in the Western countries. However, its real prevalence
is underestimated due to the frequent self-medication.
The aim of this consensus statement is to provide evidence-based data to allow an individualized and appropriate manage-
ment and treatment of HD. The strategy used to search for evidence was based on application of electronic sources such as
MEDLINE, PubMed, Cochrane Review Library, CINAHL, and EMBASE.
These guidelines are inclusive and not prescriptive.
The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria
adopted by American College of Chest Physicians. The recommendations were graded A, B, and C.

Keywords  Hemorrhoids · Hemorrhoidal disease · Conservative treatment · Office-based procedures · Surgical treatment ·
Special conditions · Postoperative complications

Methodology

These guidelines were based on the last Italian Society of

Colorectal Surgery (Società Italiana di Chirurgia Coloret-
* M. Trompetto tale; SICCR) clinical practice guidelines for the evaluation
[email protected] and management of hemorrhoidal disease (HD) published
in 2015 [1]. The goal of this consensus statement was to
1
Department of Surgical and Medical Sciences, University establish an evidence-based approach to HD.
“Magna Graecia” of Catanzaro, Catanzaro, Italy
The strategy Electronic sources such as MEDLINE, Pub-
2
Department of Colorectal Surgery, Santa Rita Clinic, Med, Cochrane Review Library, CINAHL, and EMBASE
Vercelli, Italy
were searched from March 1, 2009 to March 1, 2019.
3
Department of General, Emergency and Minimally Invasive Keywords combinations included were hemorrhoids,
Surgery, Careggi University Hospital, Florence, Italy
hemorrhoidal disease, internal and external hemorrhoids,
4
Proctological and Perineal Surgical Unit, Cisanello thrombosed external hemorrhoids, sclerotherapy, rubber
University Hospital, Pisa, Italy
band ligation, Hemorrhoidal Laser Procedure (HeLP),
5
Department of General Surgery, Tor Vergata University, Doppler-guided hemorrhoidopexy, Ferguson (closed) and
Rome, Italy
Milligan–Morgan (open) hemorrhoidectomies, excisional
6
Operative Unit of General Surgery, IRCCS de Bellis, hemorrhoidectomy, postoperative pain, anal stenosis, early
Castellana Grotte, Bari, Italy
and delayed bleeding, complications, special conditions, and
7
Department of Surgical, Oncological and Stomatological minimally invasive procedures.
Disciplines, University of Palermo, Palermo, Italy
The criteria used to select evidence were study design
8
Department of Colorectal Surgery, Whipps Cross University [randomized-controlled trial (RCT), prospective and retro-
Hospital, Barts Health, London, UK
spective observational studies, case series, and systematic
9
Department of General and Minimally Invasive Surgery, reviews], the presence of primary and secondary outcomes,
University of Turin, Turin, Italy

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146 Techniques in Coloproctology (2020) 24:145–164

study methodology (sampling, blinding, and analytical Pain is rare in case of uncomplicated HD. In fact, its pres-
methods), English language, and the evaluation of papers ence may indicate other simultaneous painful conditions
published only in indexed journals with impact factor. Pro- (fissure, abscess, pudendal neuropathy, proctalgia fugax,
spective randomized-controlled trials and meta-analyses and anorectal neoplasm). Acute edema and thrombosis of
were given preference in developing these guidelines. external hemorrhoids (TEH) are responsible for acute anal
Directed searches of the embedded references from the pain irrespective of bowel movements. Although several HD
candidate articles were also performed. symptom scores have been proposed so far [10–12], to date,
The recommendations were defined and graded based on none are widely used or considered the gold standard evalu-
the current levels of evidence and in accordance with the ation tool, even though after the publication of the HubBLe
criteria adopted by the American College of Chest Physi- Trial [13, 14], the use of these scoring systems has increased
cians (Table 1) [2]. to more easily compare data from the scientific literature.
Three evidence levels were defined. The recommenda-
tions were graded A, B, and C. Classification and scoring system for HD
Members of the SICCR were invited to contribute to the
production of these guidelines and final recommendations HD classifications should meet the need to choose the most
were reviewed by the entire Clinical Practice Guidelines suitable therapeutic approach as well as to have shared
Committee. SICCR Clinical Practice Guidelines are updated parameters for trials and guidelines.
every 4 years. Internal hemorrhoids are classified according to the pres-
ence and severity of prolapse as in the Goligher Classifica-
tion [15].
Unfortunately, the Goligher classification has several
Target users
limitations, because it does not consider the associated
symptoms and their impact on quality of life, the etiopatho-
The target users of guidelines are coloproctological sur-
genesis of the disease, and specific clinical conditions such
geons, gastroenterologists, general practitioners, nurses,
as circumferential prolapse or single prolapsed pile.
and other medical specialists who treat anoperineal diseases.
Therefore, it may not reflect the true severity of the dis-
The guidelines may be used to inform clinical decisions
ease and the effect of HD on the patient.
and standards of care. The guidelines are also intended to
To overcome these limitations, different grading systems
inform patients about the possible alternatives for the man-
have been developed. All the grading systems are patient
agement of their condition.
self-reported assessments focusing on the presence and
frequency of different symptoms. Nystrom in 2009 used
Introduction: symptoms, classification, scoring a five-point-based questionnaire assessing the frequency
system and diagnosis of HD of pain, discomfort, itching, soiling, and need for manual
reduction of hemorrhoids [11]. The system is easy to use
HD is the most common proctological disease with an esti- and reproduce and has been successfully validated [13], but
mated prevalence rate of 4.4%, with a peak in individuals it fails to consider the presence and frequency of prolapse
between 45 and 65 years of age [3]. Furthermore, 50% of that does not need manual reduction. However, hemorrhoi-
the population over 50 years old have experienced problems dal prolapse is a very important manifestation of HD and
related to HD. can impact on quality of life. Furthermore, the frequency of
Symptoms of HD may overlap with those of other ano- the symptoms was divided in four grades including “never”,
rectal conditions such as skin tags, abscesses, fissures, “less than once a week”, “1–6 times per week”, and “every
polyps, inflammatory bowel disease (IBD), and anorectal day”. Other grading systems assessing frequency of symp-
neoplasms. The most common presentation of HD is pain- toms of hemorrhoids, similarly to those assessing severity of
less rectal bleeding that occurs during or immediately after other conditions such as fecal incontinence, are based on five
defecation. Usually, it is mild–moderate bright red bleeding grades of frequency including” between never and less than
which the patient observes on the feces or staining the toi- once a week”. Yet, probably, the most important flaw of the
let paper [4–7]. Recurrent bleeding may result in secondary Nystrom system is the lack of a score for the quality of life.
iron deficiency anemia. Sometimes, HD may cause mas- HD is a benign condition and its severity is not only related
sive hemorrhage requiring urgent hospitalization and blood to the frequency of its symptoms but rather to how they
transfusions [8, 9]. Other symptoms to consider are swell- are perceived by the patient. Indeed, similar symptoms may
ing, prolapse, soiling, perianal skin irritation, itching, and affect patients’ life style and quality of life in very differ-
discomfort. Furthermore, large hemorrhoidal prolapse may ent ways with a significant variation from patient to patient.
cause sense of rectal filling and, rarely, difficult defecation. For this reason, quality of life should be considered when

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 Table 1  Grades of recommendation, assessment, development, and evaluation system grading recommendations
Description Benefit vs risk and burdens Methodological quality of supporting Implications
evidence
Techniques in Coloproctology (2020) 24:145–164

1A Strong recommendation, high-quality Benefits clearly outweigh risk and burdens RCTs without important limitations or Strong recommendation, can apply to most
evidence or vice versa overwhelming evidence from observational patients in most circumstances without
studies reservation
1B Strong recommendation, moderate-quality Benefits clearly outweigh risk and burdens RCTs with important limitations (inconsist- Strong recommendation, can apply to most
evidence or vice versa ent results, methodological flaws, indirect patients in most circumstances without
or imprecise) or exceptionally strong reservation
evidence from observational studies
1C Strong recommendation, low- or very-low- Benefits clearly outweigh risk and burdens Observational studies or case series Strong recommendation but may change when
quality evidence or vice versa higher quality evidence becomes available
2A Weak recommendation, high-quality evi- Benefits closely balanced with risks and RCTs without important limitations or Weak recommendation, best action may differ
dence burdens overwhelming evidence from observational depending on circumstances or patient or
studies societal values
2B Weak recommendations, moderate-quality Benefits closely balanced with risks and RCTs with important limitations (inconsist- Weak recommendation, best action may differ
evidence burdens ent results, methodological flaws, indirect depending on circumstances or patients’ or
or imprecise) or exceptionally strong societal values
evidence from observational studies
2C Weak recommendation, low- or very-low- Uncertainty in the estimates of benefits, Observational studies or case series Very weak recommendations;
quality evidence risks, and burden; benefits, risks, and other alternatives may be equally reasonable
burden may be closely balanced

RCTs Randomized-controlled trials

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assessing the severity of HD. In 2011, Giordano et al. pre- and risk factors such as constipation, a low fiber diet, sed-
sented a similar system [16]. The severity of hemorrhoidal entary lifestyle, and pregnancy. History of longstanding or
symptoms was scored using a specifically designed question- uncontrolled portal hypertension should be considered for
naire assessing five different parameters each one scoring differentiate HD from anorectal varices [23]. Moreover, his-
from 0 to 4 points, with zero indicating no symptoms and tory of IBD and symptoms related to impaired anal conti-
four daily symptoms or symptoms with every defecation. A nence should be investigated to plan the most appropriate
score of zero corresponds to the complete absence of hemor- treatment.
rhoidal symptoms, while 20 corresponds to the worst pos- Physical examination should confirm the presence of HD
sible symptoms. The five parameters assessed are bleeding, ruling out other anorectal diseases. It should include inspec-
prolapse, need for manual reduction, pain, discomfort, and tion of the perianal tissues, anorectal digital examination,
discharge as one parameter and impact on quality of life. and the evaluation of hemorrhoidal prolapse degree during
This very simple and intuitive system has been proved use- straining. The anorectal mucosa should be examined with
ful and effective within clinical trials [17, 18]. Sodergren an anoscope. The Sims position should be preferred because
et al. [10] elaborated a more complex dedicated scoring sys- less embarrassing for the patient than prone position.
tem based on symptoms as reported by patients, taking into Patients with HD and rectal bleeding should undergo
account how individual symptoms impact on patients’ qual- colonoscopy to rule out other colorectal diseases (Level
ity of life. Based on their findings, the most relevant symp- of evidence: 1; Grade of recommendation: B)
toms were selected and scored according to their frequency
not in a linear way but according to what their expected In Western countries, HD is one of the most frequent causes
impact on patients’ quality of life would be. Very surpris- of severe acute lower gastrointestinal bleeding [8, 9]. Nev-
ingly, the authors focused strictly on symptoms and the need ertheless, rectal bleeding is a common early symptom of
for manual reduction was not considered. Yet, although colorectal cancer [24], as well as of other colorectal diseases
strictly speaking this may not be a symptom, it is certainly such as IBD, diverticular disease, and angiodysplasia. For
an important sign of severity of HD and its frequency can this reason, patients with rectal bleeding should undergo
impact on quality of life. While the work done by Soder- colonoscopy to rule out these diseases.
gren and colleagues is very interesting and provides useful Colonoscopy should be mandatory in older patients and
information about how this condition affects patients quality when there is a personal and/or a family history of colorectal
of life, it was validated on a small sample size (n = 45) and neoplasms or documented advanced adenoma, IBD, history
it is not tailored to individual patients. It takes for granted of altered bowel habits, recent significant weight loss, and
that all patients suffering with HD are affected in the same a laboratory findings of iron deficiency anemia or a posi-
way by each individual symptom, but this may not be neces- tive fecal immunochemical test (FIT) and guaiac-based fecal
sarily always the case. Furthermore, because the score for occult blood test (gFOBT) [25–30].
each symptom is not linear, the system is not very easy to Flexible sigmoidoscopy may be associated with other
memorise and could be difficult to use in everyday practice. screening modalities, such as gFOBT or FIT, in patients
Recently, Havard et al. [12] modified the Nystrom score that are not willing or able to undergo colonoscopy [31, 32].
considering how often the patient experiences prolapse Sigmoidoscopy and colonoscopy should be integrated
instead of the need of manual reduction. Furthermore, they with anoscopy that has proven to have a higher detection
adapted the Short Health Scale (SHS), previously used in rate of perianal pathology [33, 34].
patients with inflammatory bowel disease (IBD) [19], to HD. Although an increased maximum resting anal pressure is
This system remains very faithful to the Goligher classifi- a common finding in non-prolapsing hemorrhoids [35, 36],
cation while considering the quality of life using the SHS. manometry is not routinely performed for diagnosis. Fur-
Apart from the previously mentioned system, some thermore, anorectal endosonography is not usually indicated
authors have proposed other classification [20–22] that are for the diagnosis of HD, but may disclose a thickening of
not widely used, due to their complexity. submucosal tissue as well as of the internal or external anal
sphincter [37].
Diagnosis
Conservative treatments
Diagnosis should focus on a related medical history for
specific symptoms and risk factors corroborated by phys- The goal of these treatments is the control of symptoms and
ical examination suggestive of HD (Level of evidence: 1; not the correction of pathophysiological changes.
Grade of recommendation: C). A balanced diet with adequate fiber and oral fluid intake
Diagnosis of HD should start with the collection of medi- may improve stool consistency and is one of the main pur-
cal history identifying symptoms suggestive of the disease poses of lifestyle changes of the conservative treatment for

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HD. Constipation and in particular hard stool usually worsen Another option is to sit upon a warm water bag to avoid the
symptoms related to the hemorrhoidal prolapse. A regular vacuum below the buttocks.
defecation with type 3 or 4 stool, according to the Bristol Despite its benefit, it can be difficult for the patients to
Stool Form Scale [38], without prolonged time on the toilet, perform in the hospital or at home [48].
to avoid straining during attempted defecation, may improve For this reason, another option is to sit upon a warm water
symptoms. Furthermore, the addition of anti-inflammatory bag. Furthermore, Hsu et al. demonstrated that the warm
agents or local steroids may be an effective first-line treat- water spray method can be a safe and easily performed alter-
ment and it should also be suggested as bridge to surgery. native to size bath [49]
Local therapies such as anesthetics, antiseptics, and steroids
show a temporarily relief of HD-related symptoms, but the Phlebotonics
efficacy of their prolonged application is not demonstrated
and could induce local reactions or sensitization [39, 40]. Phlebotonics has a statistically significant effect on HD-
related symptoms (bleeding, pain, itching, and symptoms
recurrence) if compared with a control group [50, 51]
Fiber and/or laxatives
(Level of evidence: 1; Grade of recommendation: B).
Phlebotonics are a heterogeneous class of drugs com-
Daily oral intake of fiber, either food or supplements,
posed by products extracted directly from plants such as
shows a consistent beneficial effect for HD symptoms
flavonoids or synthetic compounds as calcium dobesilate.
reducing the risk of bleeding, in case of an acute event,
They simultaneously increase the vascular tone and the lym-
and as the risk of not improving symptoms in about 50%
phatic drainage, decreasing vascular capacity, and stabilizing
and 47% of patients, respectively. Several trials show a
capillary permeability. However, their precise mechanism of
lack of evidence regarding a direct effect on prolapse,
action is not completely understood [50].
pain and itching (Level of evidence: 1; Grade of recom-
They are usually well tolerated with a few adverse effects.
mendation: B).
Their main side effects are mild symptoms as headache, gas-
Dietary fiber intake is generally used in patients with
trointestinal symptoms, or tingling sensations [52].
I–II-degree HD even if it can be effective in more advanced
Furthermore, a prolonged exposition to high levels of
stages. Fiber restores the normal frequency of bowel move-
flavonoids (many times more than their common dietary
ment thanks to the increase in fecal mass, volume, and soft-
sources), through an unbalanced diet or by supplementa-
ness. Fiber should be associated with an adequate oral fluid
tion, may lead to an excess of reactive oxygen species forma-
intake, although its efficacy in treating constipation remains
tion and subsequent deoxyribonucleic acid (DNA) damage.
controversial [41, 42]
These effects may be relevant during pregnancy, because
Stimulant laxatives or osmotic agents have been shown
flavonoids can cross the placenta [53].
to be effective for the treatment of HD symptoms in sev-
A meta-analysis [54] including 14 trials and 1514 patients
eral randomized trials with consistent results over time in
found that the use of flavonoids decreases the risk of worsen-
reducing the risk of bleeding as well as the risk of persisting
ing or persisting symptoms by 58% [relative risk (RR) 0.42
symptoms if compared with the placebo group [43]. How-
(95% confidence interval (CI) 0.28–0.61)] and showed an
ever, the methodology was often too weak to draw the final
apparent reduction in the risk of bleeding [RR 0.33 (95% CI
conclusions and more attention needs to be given to the cost-
0.19–0.57)], persistent pain [RR 0.35 (95% CI 0.18–0.69)],
effectiveness ratio.
itching [RR 0.65 (95% CI 0.44–0.97)], and recurrence [RR
0.53 (95% CI 0.41–0.69)]. However, limitations in the qual-
Sitz bath ity and heterogeneity of the trials examined make this con-
clusion unreliable leaving open the question about the real
A sitz bath with warm water (not exceeding 40–42 °C for efficacy of phlebotonics.
3 min) is a traditional and frequently recommended remedy
for a variety of anal disorders including HD [44]. Unfortu- Traditional Chinese medicine
nately, the proper instructions to execute it are rarely given
to patients [45]. Traditional Chinese medicine is based on the use of medici-
There is a lack of RCTs defining the role of sitz bath with nal herbs.
warm water in the treatment of HD-related pain (Level of In the nine published trials included in a Cochrane
evidence 2; Grade of recommendation C). review, the herbs are divided into two types: patent
Pain relief may be related to internal sphincter relaxation herbal medicine or the self-produced compound. The
with a decrease of anal resting pressure [46] according to the most frequent herbs used are: Radix Sanguisorbae, Radix
thermosphincteric reflex described by Shafik in 1993 [47]. Rehmanniae, Fructus Sophorae, Radix Angelicae Sinensis,

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150 Techniques in Coloproctology (2020) 24:145–164

Radix Scutellariae, and Cacumen Biotae. Their dosage is A Dutch national survey demonstrated the superiority of
rarely reported resulting in a huge bias which limits the RBL for II-degree HD and of excisional procedures for III-
study reproducibility [55]. degree HD [69].
Traditional Chinese herbs were not proved as useful for In RBL, bleeding stops in up to 90% and improvement in
stopping bleeding from hemorrhoids in a Cochrane Review II-degree HD has been shown in 93–100% of patients (63,
[55] (Level of evidence: I; Grade of recommendation: B). 64, 70). Furthermore, III-degree HD improves in 78–83.8%,
but IV-degree prolapse should have a more invasive treat-
ment [70, 71].
Outpatient treatments The possible minor complications of the technique
include pain, bleeding, thrombosis, and skin tags [70].
Rubber band ligation (RBL) Unfortunately, rare but severe complications such as mas-
sive gastrointestinal hemorrhage [72], liver abscesses [73],
RBL is the most popular non-invasive procedure [56] and endocarditis [74], perineal sepsis, and also death [75] were
should be used for the treatment of I, II, and III-degree described after RBL.
HD that fails conservative treatment(Level of evidence:
1; Grade of recommendation: B). Sclerotherapy
A rubber band is applied to the base of the internal hem-
orrhoid, above the dentate line to avoid severe pain, causing Injection Sclerotherapy (IS) should be used for the treat-
ischemic necrosis, fibrosis, and fixation of the remaining ment of I–II and III-degree HD that fail conservative
mucosa. Usually, the necrotic hemorrhoidal tissue drops out treatment (Level of evidence: 1; Grade of recommenda-
within the following 7–10 days. tion: B)
According to a recent Italian survey of over 32,000 IS, initially described by  Morgan in England in 1869
patients, II-degree HD is treated with RBL in over 90% of [76], is the injection of sclerosing agents at the apex of the
the patients [57]. RBL is contraindicated in patients on anti- internal hemorrhoidal complex, above the dentate line, lead-
coagulants or with a bleeding disorder, thrombosed hemor- ing to moderate tissue destruction with scarring, fibrosis,
rhoids, concomitant anorectal sepsis, anal fissures, abscess and fixation of the hemorrhoidal tissue. Several sclerosing
and fistula, colitis, colorectal tumors, pregnancy, immuno- agents have been described and used [5% phenol in almond
deficiency, and diabetes mellitus. oil, aluminum potassium sulfate and tannic acid (ALTA),
Although the procedure is often avoided in patients with and 50% dextrose water].
anticoagulants, according to one of the largest retrospec- Among these agents, ALTA seems to be the most effec-
tive studies regarding RBL, only 2.9% of the patients taking tive one, even if in low resource countries, 50% dextrose
warfarin or anti-inflammatory drugs bled post-procedure water could be a safe and effective alternative [77-85].
[58]. These results were confirmed by Hite al [59], who Moser et al. [79] in 2007 introduced foam sclerotherapy
demonstrated that Clopidogrel does not increase bleeding with polidocanol 3%. Subsequently, the authors compared,
complications in the postoperative period. in a randomized, controlled, single-blind, multicenter trial,
A recent cost-effectiveness analysis [60] of 2026 patients polidocanol foam with liquid polidocanol in the treatment
undergoing RBL for symptomatic HD with six board-cer- of I-degree symptomatic HD demonstrating the superior-
tified colorectal surgeons between March 2012 and March ity of the foam, after 12-week-follow-up, regarding success
2017 stated that RBL had a lower average estimated cost rate after one IS session (58/66 pts 88% vs 44/64 pts 69%;
and a lower average quality-of-life deficit per patient if p = 0.01), number of session required for success [1.08
compared with hemorrhoidal artery ligation (HAL), stapled (± 0.32) vs 1.42 (± 0.64); p < 0.001), and total amount
hemorrhoidopexy (SH), or surgical hemorrhoidectomy. In of injected polidocanol (35 mg (± 10) vs 85 mg (± 38);
this review, only 6% of the entire cohort required surgical p < 0.001). Only one adverse drug reaction (acute prostati-
treatment; meanwhile, most of the patients solved the prob- tis) was observed in the foam group. After that complication,
lem with further banding procedures. In fact, repeated RBL the authors modified the injection technique placing the first
treatment were reported in 8–10% of patients, with a recom- injection at 11 o’clock.
mended 4-week interval between the sessions [14, 61-68] Probably, the low dose of drugs used for the foam injec-
In the HubBLe trial [14], 185 patients were assigned to tion will lead to a decrease of the complication rate.
the HAL group and 187 to the RBL group. Patients treated Several studies reported a 92–100% improvement in
with RBL had a lower rate of pain (1 versus 5) and bleeding bleeding of patients with II- and III-degree HD with the use
requiring transfusion (1 versus 2) but a higher rate of recur- of IS [70, 77, 81, 83]. Resolution of prolapse was reported
rence. However, patients may prefer RBL as the first-line in 85–94% of patients with II–III-degree hemorrhoids with
treatment. 5 year follow-up [70, 77, 81].

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Techniques in Coloproctology (2020) 24:145–164 151

Subjective moderate/excellent improvement was reported Numerous studies on short-term outcomes have demon-
in 70–92% of patients suffering from III- and IV-degree HD strated that when compared to conventional hemorrhoid-
[81, 84]. Recurrence of prolapse is currently 15% at 1 year ectomy, SH is quicker to perform and patients experience
in unselected II degree [81, 86]; meanwhile, the failure rate less postoperative pain, postoperative bleeding, wound
at 1 year was reported to be, respectively, 25% and 80% in complications, and constipation [96-101]. Hospital stay
III-degree HD patients treated with ALTA and 5% phenol and time to return to normal activities were also shorter.
in almond oil [81, 82]. Furthermore, the requirements for non-surgical and surgical
Patients reported a relatively low rate of postoperative reinterventions and the readmission rate are similar follow-
pain (24–49%) [79, 86]: the intra-procedural injection was ing SH and conventional hemorrhoidectomy [99]. However,
painful in up to 90% [81]. Bleeding is rare. meta-analyses looking at long-term outcomes after SH and
Mucosal ulceration is one of the most frequent complica- conventional hemorrhoidectomy found significantly higher
tions, reported in 3.6% of patients [81]. Major complications recurrence rates following SH [99-101].
including impotence, severe acute liver injury, fistula forma- The higher recurrence rate was confirmed by a recently
tion [87], fatal necrotizing fascitis, and abdominal compart- published retrospective study that analyzed the long-term
ment syndrome following sclerotherapy have been reported outcome (15-year follow-up), of 257 patients who underwent
[88-91]. SH [102]. Follow-up data were available in 140 cases even if
only 116 answered the questionnaire regarding recurrence.
55 patients reported the recurrence of at least one hemor-
Infrared coagulation
rhoidal symptom and 17 patients required a further surgical
treatment. Large capacity stapling devices may lead to better
Infrared Coagulation (IRC) should be used for the treatment
results, but this remains unclear [103, 104].
of I-II and III-degree HD that fail conservative treatment
SH is more expensive than traditional excisional surgery.
(Level of evidence: 1; Grade of recommendation: B).
The cost–utility analysis indicates that SH has < 0.1% prob-
It consists of the exposure of the internal hemorrhoids to
ability of being cost-effective at £20,000 and 0.1% prob-
infrared waves, resulting in a protein coagulation and necro-
ability of being cost-effective at a £30,000 willingness to
sis, immediately visible as a white spot.
pay threshold [105] (Level of evidence: 1; Grade of recom-
Dimitrolopoulus et al. [92] reported a success rate of
mendation: A).
78%, 51%, and 22%, respectively, for I-, II-, and III-degree
Although all major prospective randomised trials have
HD with a cumulative subjective improvement of 81–93%
failed to demonstrate any significant adverse event related
for I–II-degree HD [93, 94].
to the use of SH, in up to 10% of these patients, several com-
The most frequent complication of IRC is a post-proce-
plications were observed [99]. Numerous minor and major
dural pain which occurs in 16–100% of patients [92, 95].
complications have been widely reported outside the major
The incidence of postoperative bleeding is 15–44% [92, 95].
trials [106, 107] (Level of evidence: 2; Grade of recom-
Recurrence of bleeding is reported in 13% of patients
mendation: C).
at 3-month follow-up [92, 95]. Data are insufficient for the
assessment of the long-term efficacy of the technique.
Transanal hemorrhoidal dearterialization (THD) or
Doppler-guided hemorrhoidal artery ligation (DGHAL)
Non‑excisional procedures
THD or DGHAL is a treatment option for II- and III-
Stapled hemorrhoidopexy degree haemorrhoids and in experienced hands possibly
also for IV degree [18, 108, 109] (Level of evidence: 1;
Grade of recommendation: A).
SH is an effective technique for the treatment of HD.
When compared with conventional hemorrhoidectomy, THD/DGHAL is associated with decreased postoperative
SH is associated with less operating time, earlier return pain, reduced postoperative events, and faster recovery
of bowel function, shorter hospital stay, less pain, a faster than excisional hemorrhoidectomy, but carries higher
functional recovery with shorter time off work, an earlier recurrence rates (Level of evidence: 1; Grade of recom-
return to normal activities, and better wound healing mendation: A).
(Level of evidence 1; Grade of recommendation: A). Following THD, fewer patients had postoperative bleed-
However, the incidence of recurrence and the need for ing compared with open hemorrhoidectomy or SH. THD
additional operations are also significantly higher when is associated with fewer emergency reoperations than
compared to conventional hemorrhoidectomy (Level of open, closed, stapled and LigaSure™ procedures, with a
evidence 1; Grade of recommendation: A). high probability of being the best treatment regarding this

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152 Techniques in Coloproctology (2020) 24:145–164

outcome (p = 0.710) [110]. In addition, it has been shown Excisional procedures

that compared to more invasive surgical techniques THD
is associated with shorter operating time, less postopera- Excisional hemorrhoidectomy
tive complications, and notably decreased postoperative
pain. This resulted in a shorter length of hospital stay and The traditional excisional methods (Milligan-Morgan, Fer-
an earlier time to the first bowel movement [110]. Work or guson procedures) still remain the first choice and the most
normal daily activities were also resumed quicker follow- common indication for symptomatic III- and IV-degree HD
ing THD (p = 0.09) [111]. However, Other studies demon- (Level of evidence: 1; Grade of recommendation: A).
strated that compared with hemorrhoidectomy, dearteri- Open hemorrhoidectomy (OH) and closed hemorrhoid-
alization with mucopexy resulted in similar postoperative ectomy (CH) are both efficient surgical procedures for the
pain and morbidity and a similar 24-month cure rate [112, treatment of HD, despite the presence of some disadvantages
113] (Level of evidence: 2; Grade of recommendation: due to the extent of dissection as well as to the presence of
B). wounds below the dentate line with postoperative pain that
Three studies comparing the use of Doppler to a blinded can be severe delaying the return to normal daily activities.
transfixation suggested that operative time was signifi- According to a recent meta-analysis [121] of 11 RCTs and
cantly longer and the postoperative pain score higher 1326 patients comparing OH and CH, the Ferguson proce-
with the use of Doppler, while there was no difference in dure was associated with reduced postoperative pain, faster
recurrence rates [114-116]. However, bias regarding tech- wound healing, lesser risk of postoperative bleeding, and
nique and instrumentation used in these studies make their longer procedure time (Level of evidence: 1; Grade of rec-
results difficult to interpret and as such the quality of the ommendation: A).
data is not good enough for a recommendation. Radiofrequency hemorrhoidectomy is a sutureless
When compared to SH, THD was associated with sig- technique dependent on a modified electrosurgical unit to
nificantly less postoperative pain. Both techniques were achieve tissue and vessel sealing. It results in less blood
equally effective in the short term with similar rates of loss, postoperative pain, and complications. It is technically
complications and recurrence [16, 117-120] (Level of evi- simple, because suturing is not required and hemostasis is
dence: 1; Grade of recommendation: B). easy to achieve [122]. It has the potential of making hemor-
The recurrence rate following THD/HAL seems to be rhoidectomy into a day-care regimen (Level of evidence: 1;
influenced by surgical experience. Overall recurrence rate Grade of recommendation: B).
ranges between 3 and 24% (HAL 3.3–24%; THD 3–20%) Pain following hemorrhoidectomy is well described
with reintervention, to treat recurrent symptoms, necessary in the literature and seems to be less after radiofrequency
in 2.7–22% of patients (HAL 2.7–22%; THD 4.1–17.8%) hemorrhoidectomy [123-125]. Postoperative bleeding is
[17]. reported in up to 3% of patients (OH range 0.2–5%; CH
The use of a mucopexy has become a routine part of range 0–4%). The overall recurrence rate is between 2 and
the procedure though, in patients with bleeding as the 8% (OH 2.8–7.8%; CH 2–8%). Fecal incontinence follow-
only symptom, dearterialization alone may suffice. In ing hemorrhoidectomy is reported as 6% with no significant
the presence of any degree of hemorrhoidal or mucosal difference between OH and CH [126]. There is no difference
prolapse, mucopexy should be added to the dearterializa- between OH and CH  regarding the rate of fecal impaction,
tion. A THD technique with targeted mucopexy has been anal stenosis, anal fissure, and some loss of the sensitive
described as the best way to tailor this procedure to each anal mucosa [110].
individual patient [58].
Pain following THD can occur in up to 38% of oper- Management of HD in special conditions
ated patients (HAL range 0–38% of patients; THD range
0–35% of patients). Yet, in the majority of series, the inci- Pregnancy
dence of postoperative pain was less than 10%. Postopera-
tive bleeding was reported in up to 18% of patients (HAL The prevalence of symptomatic hemorrhoids is higher in
range 0.9–18%; THD range 0–13%) and, in rare instances, pregnant than in non-pregnant women.
required hospital admission and reintervention. Other Pregnancy and spontaneous vaginal delivery are well-
postoperative events include tenesmus, which is more fre- established predisposing factors for the development of HD
quent in patients who underwent mucopexy, hemorrhoidal in females due to the increased intra-abdominal pressure
thrombosis, observed in up to 8.6% of patients (HAL range from uterine growth, the hormonal changes, and constipation
2.3–6.7%; THD range 0–8.6%), and anal fissure (2.1% of (38% of the pregnant females). Clinical reports demonstrated
patients; HAL range 0.9–2.1%; THD range 0.6–1.5%). that HD is mostly prevalent in the last trimester of pregnancy
Transient fecal urgency has also been reported [17]. and in the first month after delivery, with about 25–35% of

13
Techniques in Coloproctology (2020) 24:145–164 153

the pregnant females suffering from this disease [127, 128]. topical nifedipine [138], and botulinum toxin injection
In particular, thrombosed external hemorrhoids (TEH) are [139] are reliable options especially in delaying or avoid-
more frequent during the last trimester of pregnancy and ing a surgical procedure.
immediately after delivery (7.8% and 20%, respectively). Conservative treatment for prolapsed thrombosed inter-
The prevalence of symptomatic hemorrhoids in pregnant nal haemorrhoids, if compared with urgent hemorrhoid-
females is higher with the increase in age and parity [129, ectomy, is associated with a shorter inpatient stay and
130]. Insufficient data exist on the safety of anti-hemorrhoi- less anal sphincter damage than operative treatment [140]
dal treatment in pregnancy. (Level of evidence: 1; Grade of recommendation: B).
Patients with I- and II-degree HD may benefit from oral Excision has been shown to have better results in terms
rutosides for symptom relief. However, their use cannot be of reduction of pain, recurrences, and number of skin
recommended until new evidence about their safety is avail- tags in comparison to simple incision and conservative
able [131] (Level of evidence: 1; Grade of recommenda- treatment with glyceryl trinitrate (GTN) (p < 0.001) [141]
tion: B). (Level of evidence: 1; Grade of recommendation: B).
Sitz baths have been shown to be a statistically significant A literature search [142] considering 800 articles on
choice in achieving a complete healing of HD in pregnant hemorrhoids stated that excision allows better results than
females compared to conservative treatment with an ano- incision or topical GTN meanwhile symptoms last over
rectal cream (p < 0.005) [132–134] (Level of evidence: 2; 3 weeks with conservative treatment (Level of evidence: 1;
Grade of recommendation: C). Grade of recommendation: B). This latter can be avoided
Although there is a tendency toward conservative treat- by combining topical nifedipine and lignocaine rather than
ment, hemorrhoidectomy (CH) has been successfully per- using lignocaine alone (Level of evidence: 1; Grade of
formed without risk to the fetus [134]. In fact, excisional recommendation: B).
surgery should be considered, especially in case of hypoten- Thus, most patients with TEH benefit from surgical
sive risk due to postoperative bleeding. In this case, excision excision within 72 h of the onset of symptoms [143] (Level
of the symptomatic pile is required (Level of evidence: 2; of evidence: 1; Grade of recommendation: B).
Grade of recommendation: C). These data were confirmed by Jongen and Coll [144]
According to Mirhaidari et al. [135], an excision under who conducted a retrospective analysis of complication
local anesthesia in an outpatient regimen of the thrombosed rates, symptom recurrences, long-term results, and patient
pile/s can be easily performed without any special monitor- satisfaction after outpatient excision (local anesthesia)
ing as well as any risk of preterm labor or miscarriage (Level of TEH in 340 patients. They concluded that outpatient
of evidence: 2; Grade of recommendation: C). excision of TEH under local anesthesia can be safely per-
There are no safety data available for any of the com- formed with a low recurrence and complication rate and
pounds commonly used for HD during pregnancy. Thus, it with a high level of patient acceptance and satisfaction
should be treated by increasing fiber and oral fluid intake, (Level of evidence: 2; Grade of recommendation: C).
administering stool softeners, improving toilet habits, and Zuber [145] proposed hemorrhoidectomy for TEH. He
sometimes by adding topical treatment [132]. suggested that hemorrhoidectomy be performed through an
The course of HD tends to be longer during pregnancy elliptic incision over the site of thrombosis with removal
and most symptoms will resolve spontaneously after deliv- of the entire diseased hemorrhoidal plexus in one piece.
ery, with a few cases requiring a surgical evaluation during He underlined that caution must be exercised to avoid
pregnancy or after delivery. cutting into the muscle sphincter below the hemorrhoidal
vessels. Infection after suture closure is rare secondary to
Thrombosed hemorrhoids the rich vascular network in the anal area. Stool softeners
must be prescribed postoperatively to help prevent tearing
TEH can be easily recognized on physical examination as at the suture line. Moreover, training and experience in
usually tender visible blue perianal/anal lumps. TEH most general and skin surgery are necessary before the physi-
frequently causes acute and severe pain, but the severity of cian attempts this procedure unsupervised.
the symptoms depends on the size of the thrombus. Without SH is a feasible treatment for selected patients with an
intervention, the pain typically gets better over 2–3 days, acute hemorrhoidal crisis and has a similar complication
with a continuous improvement as the thrombus gradually rate if compared with a conventional excisional hemor-
absorbs over several weeks. Analgesics and stool softeners rhoidectomy. SH is associated with less postoperative
may be beneficial. pain, shorter operation time, a shorter hospital stay, and
Heparin treatment [136], a highly standardized and an earlier return to normal activities [146] (Level of evi-
bioavailable mixture of flavonoids and triterpenes [137], dence: II; Grade of recommendation: B).

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154 Techniques in Coloproctology (2020) 24:145–164

However, older patients with anemia or a prolonged hem- Thornhill et al. [155] reported severe complications in the
orrhoidal crisis are unsuitable for stapled hemorrhoidectomy treatment of HD in patients with radiation proctitis (Level of
[147] (Level of evidence: II; Grade of recommendation: C). evidence: 2; Grade of recommendation: C).
After radiation in the pelvic region, most symptoms are
linked to the radiotherapy and not to the HD. For this rea-
Immunosuppressed patients son, any invasive procedure for benign disease, especially
for hemorrhoidal-like symptoms, must be strongly discour-
HD is common in patients with acquired immunodeficiency aged [156].
syndrome [AIDS], often resulting from chronic diarrhea
brought on by medications. Coagulopathies
As suggested by Gupta [148], selective management
will result in high rates of symptomatic relief and complete The frequent use of anticoagulants has likely led to an
wound healing after HD surgery without excessive morbid- increased incidence of bleeding in patients with a clinically
ity and mortality. significant internal hemorrhoids. Society guidelines recom-
Even if the indications for hemorrhoidectomy in patients mend that anticoagulation be suspended prior to hemorrhoi-
with AIDS need to be considered extremely carefully dal surgery and procedures.
because of the high incidence of delayed wound healing However, there is no consensus regarding the exact
[149], nowadays, there is no significant increase in compli- indications for surgery in patients with HD affected by
cation rate for patients with a low CD4 + T-cell count (< 200/ coagulopathy.
μL) compared to those with a higher count [150] (Level of As already described, Hite et al. [59] reported that the
evidence: I; Grade of recommendation: C). risk of a bleeding complication after RBL for  HD does not
Recently, Fan and Coll [151] reported that tissue-select- appear to be increased in patients taking clopidogrel (Level
ing therapy stapler (TST) for prolapsing hemorrhoids in of evidence: 1; Grade of recommendation: C). These results
human immunodeficiency virus (HIV)-infected patients is were confirmed by Atallah et al. [157] who reveal that THD
a safe technique with a low complication rate and minor can be performed on anticoagulated patients without cessa-
technical difficulties, especially for HIV-infected patients tion of oral agents without an increased risk of postopera-
who have a high satisfaction index (Level of evidence: 2; tive bleeding. Nevertheless, Albuquerque [158] suggested
Grade of recommendation: C). that secondary bleeding normally occurs 10–14 days after
In conclusion, there is no evidence for the best treatment RBL and patients taking anti-platelet and/or anti-coagulant
regarding HIV + patients with hemorrhoids. Further studies medication have a higher risk, with some reports of massive
are requested to provide some scientific evidence. Moreover, life-threatening hemorrhage (Level of evidence: 2; Grade of
no data of transplanted patients have been reported in the recommendation: C).
international literature.
Emerging technologies
 Inflammatory Bowel Disease
Embolization of the hemorrhoidal arteries
There is no consensus in the scientific literature regarding
the exact indications for surgery in patients with IBD who Embolization of the hemorrhoidal arteries, the so-called
have HD. “Embhorroid technique”, was first described for the treat-
D’Ugo et al. [152] suggested that first-line management ment of HD in 2014 by Vidal et al. [159].
should be medical therapy, considering that a spontaneous It consists in the embolization of the hemorrhoidal
healing is possible. Despite the higher risk of complications arteries, in which arterial occlusion is achieved through an
in patients with IBD [153], in non-responding patients, the endovascular approach (usually transfemoral) using coils
surgical options on a highly selective basis can be consid- placed in the terminal branches of the superior rectal arter-
ered with acceptable results [154] (Level of evidence: 2; ies. The use of polyvinyl alcohol (PVA) particles of 0.3 mm
Grade of recommendation: C). and metallic coils seems to be more effective in symptom
relief than the use of metallic coils alone. In fact, the use
of 0.3 mm particles determines a more distal hemorrhoidal
Radiation proctitis plexus embolization reducing the reloads by the middle rec-
tal arteries and avoiding rectal ischemia, because the parti-
There is no consensus in the scientific literature regarding cles do not pass the inferior rectal artery anastomoses [160].
the exact indications for surgery in patients who have had It could be performed in an outpatient setting and has
pelvic radiotherapy for malignancy. been shown to be a safe and effective technique for the

13
Techniques in Coloproctology (2020) 24:145–164 155

treatment of II–III-degree HD [161] (Level of evidence: Laser hemorrhoidoplasty

2; Grade of recommendation: C).
It should be reserved for a selected group of patients Laser hemorrhoidoplasty (LHP) is based on the applica-
with disabling and refractory hemorrhoidal symptoms and tion of the laser beam inside the hemorrhoidal tissue. After
without irreducible prolapse [162] (Level of evidence: 2; making a 1-mm opening at the cutaneous anal edge of the
Grade of recommendation: C). hemorrhoidal pile, the fiber is introduced inside the tissue
Emborrhoid showed good bleeding control in patients parallel to the anal sphincter as well as to the rectal axis.
with contraindications for conventional surgery with a The fiber is then pushed up to the upper part of the piles and
clinical score improvement in 72% of cases after the first three pulses at a power of 15 W are delivered. This maneuver
embolization session [162] (Level of evidence: 1; Grade is repeated thorough the same hole but in different direc-
of recommendation: C). tions. The laser beam induced a shrinkage of underlying
tissues up to approximately 5 mm of depth [169].
LHP seems to reduce postoperative pain, intraoperative
HeLP bleeding, and the need of postoperative analgesics if com-
pared with Milligan–Morgan procedure, with a complete
HeLP is the acronym for Hemorrhoidal Laser Procedure resolution of symptoms in about 70% of cases [169] (Level
and is based on the application of a 980-nm diode causing of evidence: 2; Grade of recommendation: B).
shrinkage of the terminal branches of the superior hemor- It is associated with shorter operative time and less
rhoidal artery [163, 164]. postoperative pain compared to excisional surgery [170].
To carefully detect the superficial arteries at approxi- Furthermore, in a recent observational study concerning 50
mately 2.5 cm above the dentate line, a 20 MHz Doppler patients with II- and III-degree HD, Brusciano et al. [171]
transducer is used. The laser energy delivered at 980 nm reported a quick return to daily activity 1 day (40%) and
wavelength at that level induces a shrinkage up to a depth 2 days (100%) after the procedures. (Level of evidence: 2;
of 4 mm, thus reducing the blood flow [165]. Grade of recommendation: C).
HeLP has been shown to be safe, effective, and easy to After a mean follow-up of 5.4 years, recurrences was
perform. It is an effective alternative for the treatment of reported in 39% and 33% of patients with II- and III-degree
symptomatic hemorrhoids, especially with bleeding and HD, respectively [172], without any statistically significant
pain as prominent symptoms, in the absence of severe differences related to the degree of HD (p = 0.761) (Level of
mucosal prolapse even if an improvement of the latter has evidence: 1; Grade of recommendation: C).
been described. This procedure can be also associate with
rectoanal repair or with mucopexy (Level of evidence: 1; Complications of surgical treatments for HD
Grade of recommendation: C).
This novel technique shares the rationale of the HAL 1. Open and closed hemorrhoidectomies have a signifi-
and THD procedures but with the potential advantage of cantly more severe negative impact in the early post-
being less invasive and not requiring general anesthesia operative period than stapled, THD, LigaSure™, and
[166] (Level of evidence: 1; Grade of recommendation: Harmonic™ hemorrhoidectomies (Level of evidence:
C). 1; Grade of recommendation: B)
The most common intraoperative procedure-related com-
plication reported is postoperative bleeding, ranging from Various studies have shown that the closed and radiofre-
5.9% to 8.8% of cases with more than a half of them needing quency hemorrhoidectomies  had significantly more postop-
an hemostatic procedure [164, 166] (Level of evidence: 2; erative complications (mainly pain) than the open, stapled,
Grade of recommendation: C). LigaSure™, Harmonic™, and THD  procedures. Further-
Short- and long-term postoperative complications rate more, OH and CH were associated with greater operative
is very low with pain as the most significant postoperative blood loss and a longer operating time compared with the
symptom. It required medications for an average of 3 days other surgical techniques. Nevertheless, a low recurrence
after surgery in around 9.5% of patients [166]. Anyway, it rate is perceived to be the most important advantage of OH
has also been reported a case of life-threatening condition and CH which were found to have a lower recurrence rate
in which it was necessary to fashion a diverting stoma due than THD and SH. Moreover, the use of energy devices
to bowel obstruction after a postoperative rectal hematoma such as LigaSure or Harmonic may reduce complication
[167]. rate, even if with increased costs [110]. Overall procedural
Symptoms recurrence ranges from 10 to 20% for II–III- complication rates of SH ranged from 2 to 68%. However,
degree HD [166, 168] (Level of evidence: 2; Grade of rec- these complications may typically occur in about 16% of
ommendation: C). procedures [147, 173, 174].

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156 Techniques in Coloproctology (2020) 24:145–164

The overall complication rates after SH and THD were hemorrhoidectomy (LigaSure), rates of bleeding between
comparable with no significant differences [175, 176]. 0 and 49% have been reported. Clinically significant bleed-
Despite a more favourable postoperative period for SH or ing has been reported in 0.3–6% of patients, with an aver-
THD/DGHAL techniques, some procedure-specific com- age of around 2%, and need of reintervention between
plications have been described, and should be considered 1–2%, without a significant difference in rates of bleeding
during preoperative discussion with the patients regarding between the procedures [121, 182, 183].
indications for surgery. Early bleeding was the most common complication
Early fecal urgency after SH has been reported, with inci- after SH, with the overall rate following the procedure
dence rates of 0—25%, and a median of 8% [173]. ranging from 0 to 68% (median 7.5%) with < 1% of post-
On the other side, postoperative tenesmus was reported operative bleeding requiring treatment [176, 184].
in up to 24% of patients and pruritus in up to 15% after Bleeding after Doppler-guided hemorrhoidal dearte-
DGHAL, especially if mucopexy was contemporary per- rialization has been reported to be low (0–22%, median
formed [177]. 4.3%); however, this needs to be balanced with the chance
Several studies described different complication rates of long-term recurrence [108].
following office procedures (such as RBL, sclerotherapy, Bleeding after RBL normally occurs between 5 and
and infrared coagulation), ranging from 3% to 18.8% [158, 14 days after treatment, probably due to the sloughing of
178]. A review of 39 studies including 8060 patients who the ligated hemorrhoids [182].
had RBL revealed post-banding complications in 14% of the However, when RBL was compared to HAL, recur-
patients, although severe complications are rarely reported rence rates (if RBL was repeated), symptom scores, com-
[179]. plications (such as postoperative bleeding), quality-of-life
Urinary retention is one of the most common complica- score, and continence score were similar, although patients
tions after surgery for  HD, with incidence rates of 3–50% had more pain in the early postoperative period after HAL.
with most studies reporting a rate around 15% [180, 181]. HAL was also more expensive and was not found to be
cost-effective compared with RBL in terms of incremental
2. Emergency reoperation may be required in about 2% cost per quality-adjusted life-year [14].
of patients after a surgical treatment for HD (Level of
evidence: 1; Grade of recommendation: B) 4. Pain: The higher levels of pain related to OH and SH
compared to other techniques resulted in a longer hos-
Up to 90% of emergency reoperations are needed to stop pital stay and a later return to normal activities. A mul-
a postoperative bleeding. Interestingly, most patients will timodal pain reliever regimen should be used to promote
not have an identifiable source of bleeding by the time which a faster recovery, prevent urinary retention, and improve
they are examined in the operating room. However, these patient satisfaction (Level of evidence: 1; Grade of rec-
bleeding episodes can be significant and a return to the oper- ommendation: B)
ating room for a second look may be justified. Intractable
pain, hematoma incision, residual hemorrhoidal thrombosis, Compared to excisional hemorrhoidectomy, THD and
and sepsis are other possible indications for reoperation. SH are followed by less postoperative pain. A number of
A network meta-analysis of the trials reporting on reop- modifications in surgical and postoperative management
eration showed that THD/DGHALprocedures were associ- have been proposed and attempted to reduce the pain, with
ated with significantly fewer reoperations than open, closed, variable results.
stapled, and LigaSure™ procedures, in large part due to Topical 2% Diltiazem or GTN ointment demonstrated
lower bleeding rate [110]. However, THD had a higher a significant pain reduction in randomized trials [185].
recurrence rate than open, closed, LigaSure, laser, and radi- Lateral sphincterotomy or botulin toxin injection also
ofrequency hemorrhoidectomy, and therefore, the highest demonstrated efficacy in reducing postoperative pain, sug-
probability of being the worst treatments regards recurrence gesting a possible role of sphincteric spasm in its patho-
of hemorrhoids. genesis. However, the risk of developing temporary or
permanent anal continence alterations limits the use of
3. Bleeding: fewer people have postoperative bleeding sphincterotomy.
after THD/DGHAL procedures compared with OH or The use of oral metronidazole in controlling postopera-
SH (Level of evidence: 2; Grade of recommendation: tive pain was recently evaluated in two meta-analysis with
B) conflicting results [186, 187].
Several other treatments such as mesoglycan [188] were
For conventional hemor rhoidectomy (Milli- recently used for pain after hemorrhoidectomy, but further
gan–Morgan and Ferguson) and bipolar energy device trials are needed to reach agreement.

13
Techniques in Coloproctology (2020) 24:145–164 157

The reported incidence of postoperative pain ranged 5. Life-threatening complications: Although extremely
from 0 to 38% with a pooled value of 15% after THD uncommon, life-threatening complications have been
procedure [175]. reported after every treatment for hemorrhoids. Sur-
Pain after SH has been attributed to the involvement of geons providing hemorrhoid treatment should be aware
the staple line on the sensitive squamous epithelium of the of the potential serious complications and alert to their
anoderm, inclusion of smooth muscle, or surrounding ano- presenting features (Level of evidence: 1; Grade of rec-
rectal tissue in the scar, and induction by the staple line of ommendation: C)
an inflammatory response in the rectal ampulla, sphincter
or rectal spasm, elevated anal resting pressures, retained Severe septic complications have been reported after
staples, fibrosis around the staple line, wound dehiscence, all types of treatments of hemorrhoids, and their real inci-
and sepsis. Although chronic pain after SH has been vari- dence is probably underestimated.
ably reported, it is typically experienced by less than 2% Complications such as rectal perforation, pelvic sep-
of patients. sis, abdominal peritonitis, pneumo-retroperitoneum or
Treatment of chronic pain following HD surgery should mediastinum, pulmonary septic embolism, liver abscess,
be targeted to the underlying source. However, it is usu- and Fournier’s gangrene, with several deaths, have been
ally quite difficult to manage and cure, which emphasizes reported [74, 107, 192, 193].
the importance of proper knowledge of the anatomy and Several infectious complications have also been
careful use of surgical techniques. reported following office procedures (such as RBL,
Warm sitz baths and non-steroidals therapies  can sclerotherapy, and cryotherapy) including pelvic sepsis,
relieve mild pain. Antispasmodics such diazepam or Fournier’s gangrene, liver abscesses, tetanus, and bacterial
cyclobenzaprine may be added if levator spasm is noted. endocarditis. Deaths due to these infectious complications
Post evacuatory pain may be treated with oral nifedipine. have been reported too [158].
Anismus may be treated with botulinum toxin injection. Even if surgery is usually considered mandatory after
For selected cases, sacral neuromodulation has also been serious septic complications, and colostomy often per-
described [189]. formed, successful conservative treatments (medical, per-
In case of chronic pelvic pain after stapler surgery, the cutaneous drainage) have been reported in selected cases.
removal of staples or staple line excision has been reported The majority of patients in whom these complications
[106, 190]. However, the evidence of these treatments is occurred were healthy before surgery, and no predisposing
low and effectiveness observed only in a low percentage factors had been identified. However, it is well known that
of patients. digital, surgical, or instrumental manipulation of the rec-
Urinary retention after hemorrhoidectomy is often mul- tum is associated with a possible 0–9.5% of transient bac-
tifactorial, with pain as one of the major issues, causing teraemia [194], often with no clinical effects. Escherichia
symptoms through irritation of pelvic nerves and activa- coli and Bacteroides are the predominant organisms that
tion of pain-evoked reflexes. cause infection following hemorrhoidectomy. The efficacy
Some risk factors are not modifiable (age, male sex, and of a routine use of prophylactic antibiotics has yet to be
type of surgery). proven, although special consideration should be given in 
In general, epidural and spinal anesthesia have been immunocompromised patients.
associated with higher rates of urinary retention compared
with monitored anesthesia care. Opioids or excess intra- 6. Long-term complications: Anal stenosis, soiling, and
venous fluid has also been shown to significantly increase alterations of anal continence or residual skin tags have
the risk of urinary retention. Usually, most problems with been reported after all the treatments for hemorrhoids,
urinary retention are self-limited, and will resolve with- without any significant difference among the surgical
out major intervention. An adequate control of pain is a treatments (Level of evidence: 1; Grade of recommen-
key point in prevention and treatment. Patients with mild dation: B)
retention are often counseled to sit in a bath of very warm
water, filled above the waist. When this is unsuccessful, Complications after hemorrhoid surgery are not always
patients may require bladder catheterization. This may immediate, and can instead take months or years to fully
involve intermittent straight catheterization or a temporary develop. In general, they can be more severe and more
indwelling catheter, which can typically be removed after difficult to treat than those occurring in the immediate
a few days without further testing. Α1 antagonists such postoperative period.
as tamsulosin can be helpful, and attempts to minimize Fifty-one trials (4793 participants; 11 treatments)
opioid intake is also worthwhile [191]. reported on the proportion of patients complaining of

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158 Techniques in Coloproctology (2020) 24:145–164

difficulty voiding owing to outlet obstruction or anal ste- Fecal incontinence can also occur after a procedure for
nosis/stricture at follow-up [110]. prolapse and  HD (reported in up to 5% of patients), and it
Anal stenosis has been reported after stapled or exci- has been related to a low-placed staple line, to an injury to
sional hemorrhoidectomy in 1–7.5% of cases [191, 195]. the internal sphincter due to the large diameter of the circu-
In these patients, the normal pliable anoderm is replaced lar stapler, or to an alteration of anorectal sensitivity or com-
by scar tissue due to excessive removal of the anoderm and pliance. In a prospective, randomized trial of 134 patients,
distal rectal or to other factors that interfere with the normal de novo fecal incontinence at 1 year was reported in 2.5% of
healing process. Concomitant injury of the underlying anal patients who had SH compared with 7.5% of patients who
sphincter muscle may also occur and contribute to the func- had a Milligan–Morgan hemorrhoidectomy [197].
tional and anatomical alteration. A functional stenosis, due
to muscle hypertonicity, should be considered when plan-
ning treatments. Compliance with ethical standards. 
Patients often report straining at defecation, smaller
caliber stools, and pain at defecation. Anal stenosis may also Conflict of interest  The authors declare that they have no conflict of
interest.
lead to fecal impaction and overflow incontinence.
Anal stenosis may be classified, according to the severity Ethical approval  Not required.
of the stricture, as mild, moderate, or severe, but its man-
agement is usually determined by the severity of symptoms Informed consent  Not required.
rather than the degree of stenosis. Mild strictures can often
be treated with dietary modifications, stool softeners, or fiber Open Access  This article is licensed under a Creative Commons Attri-
supplements. Digital dilatation or the use of anal dilators can bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
be part of the treatment plan if medical management is not as you give appropriate credit to the original author(s) and the source,
sufficient. Patients with moderate or severe strictures who provide a link to the Creative Commons licence, and indicate if changes
have failed conservative management usually require surgi- were made. The images or other third party material in this article are
cal intervention. To determine the proper surgical procedure, included in the article’s Creative Commons licence, unless indicated
otherwise in a credit line to the material. If material is not included in
the degree of involvement of the anoderm and the sphinc- the article’s Creative Commons licence and your intended use is not
ter muscle complex must be determined. In case of fibrotic permitted by statutory regulation or exceeds the permitted use, you will
anal sphincter, sphincterotomy (unilateral or bilateral) may need to obtain permission directly from the copyright holder. To view a
be considered. On the contrary, patients with stenosis of copy of this licence, visit http://creat​iveco​mmons​.org/licen​ses/by/4.0/.
the anoderm are usually treated with flap (multiple types)
or anoplasty, aiming to replace local fibrosis with healthy,
elastic tissue [182]. Flap procedures and sphincteroplasty
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