Skip to main content.

Prolapse: Coloproctology

Postoperative Anal Stenoses with Ligasure Hemorrhoidectomy.
Gravante G, Venditti D
World J Surg. 2006 Aug 29;.

Laxatives for hemorrhoids?
Guirguis-Blake J
Am Fam Physician. 2006 Aug 1;74(3):413.

Randomized clinical trial of the effects on anal function of Milligan-Morgan versus Ferguson haemorrhoidectomy.
Johannsson HO, Pahlman L, Graf W
Br J Surg. 2006 Sep 4;.e-pub

BACKGROUND:: Studies of haemorrhoidectomy usually report postoperative pain, healing and complications, but rarely consider anal function in the longer term. The primary aim of this randomized trial was to compare long-term changes in anal function after open (Milligan-Morgan) and closed (Ferguson) haemorrhoidectomy. METHODS:: A total of 225 patients were included in the trial, 115 in the open group and 110 in the closed group. Continence changes were recorded by means of validated questions and an incontinence score. Pain was self-reported using a visual analogue scale. RESULTS:: Postoperative pain and complications did not differ between the groups. Time to recovery was 17 days in the Milligan-Morgan group and 15 days in the Ferguson group. After 1 month the wounds were healed in 57.0 per cent of patients in the open group and 70.6 per cent of those in the closed group (P = 0.058). At 1 year, 78.9 per cent of the Milligan-Morgan group and 85.3 per cent of the Ferguson group reported no continence disturbance (P = 0.072). The incontinence score was improved at 1 year in the closed group (P = 0.015), but was unchanged in the open group (P = 0.645). Patients who had the Ferguson procedure were more satisfied with the outcome of surgery (P = 0.047). CONCLUSION:: Closed Ferguson haemorrhoidectomy was superior to the open Milligan-Morgan procedure with respect to long-term anal continence and patient satisfaction. Copyright (c) 2006 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.


The Vascular Nature of Hemorrhoids.
Aigner F, Bodner G, Gruber H, Conrad F, Fritsch H, Margreiter R, Bonatti H
J Gastrointest Surg. 2006 July - August;10(7):1044-1050.

The arterial blood supply of the internal hemorrhoidal plexus is commonly believed to be associated with the pathogenesis of hemorrhoids. Ultrasound-supported proctoscopic techniques with Doppler-guided ligature of submucosal rectal arteries have been introduced for the therapy of hemorrhoids. The present investigation focuses on caliber and flow changes of the terminal branches of the superior rectal artery (SRA) supplying the corpus cavernosum recti (CCR) in patients with hemorrhoids. Forty-one outpatients (17 female, 24 male; mean age 48 years) with hemorrhoids of Goligher grades I-IV were compared with 17 healthy volunteers (nine female, eight male; mean age 29 years) by means of transperineal color Doppler ultrasound. The mean caliber of the arterial branches in the study group with hemorrhoids was 1.87 +/- 0.68 mm (range, 0.6 to 3.60 mm) and 0.92 +/- 0.15 mm (range, 0.6 to 1.2 mm) in the control group (P < 0.001). The arterial blood flow was significantly higher in patients with hemorrhoids than in the control group (mean 33.9 vs. 11.9 cm/second, P < 0.01). Our findings demonstrate that increased caliber and arterial blood flow of the terminal branches of the SRA are correlated with the appearance of hemorrhoids. We suggest that the hypervascularization of the anorectum contributes to the growth of hemorrhoids rather than being a consequence of hemorrhoids. Transperineal color Doppler ultrasound (CDUS) is an appropriate method to assess these findings in patients with hemorrhoids.

Stapled hemorrhoidopexy followed by fecal urgency and tenesmus: methodological complication or surgeon's mistake?
Filingeri V, Gravante G
Tech Coloproctol. 2006 Jul;10(2):149.

Randomized controlled study: radiofrequency coagulation and plication versus ligation and excision technique for rectal mucosal prolapse.
Gupta PJ
Am J Surg. 2006 Aug;192(2):155-60.

BACKGROUND: A novel technique of radiofrequency ablation and plication of the rectal mucosa (RAMP) as a treatment for rectal mucosal prolapse is reported. The results of this technique are compared with the conventional ligature and excision procedure (LEP). METHODS: Radiofrequency ablation was performed using an Ellman radiofrequency generator. Patients with rectal mucosal prolapse were randomized to undergo either LEP or RAMP. The intra- and postoperative outcomes and complications were recorded. RESULTS: RAMP on average resulted in reduced operation time, shorter hospitalization, and significantly less postoperative pain. Return to work was earlier and wound healing times were shorter than that of patients in the control group. The complication rates also were significantly shorter (9% in the RAMP group and 29% in the conventional LEP group). CONCLUSION: The procedure of radiofrequency ablation and plication of rectal mucosa is safe, effective, and swift. It can be proposed as an effective alternative to conventional surgical procedures.

Prospective randomized clinical trial comparing two different circular staplers for mucosectomy in the treatment of hemorrhoids.
Arroyo A, Perez-Vicente F, Miranda E, Sanchez A, Serrano P, Candela F, Oliver I, Calpena R
World J Surg. 2006 Jul;30(7):1305-10.

BACKGROUND: The main objections against circular stapled mucosectomy have been anal pain and rectal bleeding during the surgical procedure or in the immediate postoperative follow-up. To avoid these consequences, a new stapler (PPH33-03) has been developed. The aim of this trial was to compare the intraoperative and short-term postoperative morbidity of stapled mucosectomy with PPH33-01 versus PPH33-03 in the treatment of hemorrhoids. METHODS: We conducted a prospective randomized clinical trial comparing hemorrhoidectomy with PPH33-01 (group 1, n=30) versus PPH33-03 (group 2, n=30) for grade III-IV symptomatic hemorrhoids. For the follow-up, the patients underwent examination and proctoscopy at 4 weeks, 3 months, and 6 months. We recorded anal pain (linear analog scale from 0 to 10), intraoperative hemorrhage, postoperative bleeding, and continence (Wexner Continence Grading Scale). RESULTS: Demographic and clinical features showed no differences between the two groups. More patients required suture ligation to stop anastomotic bleeding at surgery when the PPH33-01 stapler was used (15 versus 4, P<0.05). Rectal bleeding during the first postoperative 4 weeks was similar (P>0.05). The postoperative pain scores during the first week were similar (P>0.05). Patients with pain on defecation were fewer in the PPH-03 group (15 versus 2, P<0.05). Six patients from group 1 and none from group 2 (P<0.05) had granulomas along the line of staples at the sites of the reinforcing stitches; the granulomas were associated with postoperative anal discomfort and rectal bleeding. One patient in group 1 complained of persistent pain that resolved within 3 months. Of all the intraoperative or preoperative variables analyzed, only the presence of granuloma was associated with postoperative bleeding and anal discomfort. We have not found any recurrence or incontinence during the 6-month follow-up. CONCLUSIONS: Intraoperative bleeding along the stapled line and tenesmus or discomfort during defecation were less frequent after circular stapled mucosectomy with PPH33-03. Therefore, circular stapled mucosectomy with PPH33-03 decreases the risk of immediate complications and thus allows implantation with more safety as a day surgery procedure.


Rare colonic tumor causing intussusception.
Ramaseshan S, Saadlla H, Sury T
Gastrointest Endosc. 2006 Jul;64(1):132-3.

Technical and functional results after laparoscopic rectopexy to the promontory for complete rectal prolapse. Prospective study in 54 consecutive patients.
Auguste T, Dubreuil A, Bost R, Bonaz B, Faucheron JL
Gastroenterol Clin Biol. 2006 May;30(5):659-63.
INTRODUCTION: Laparoscopic rectopexy for complete rectal prolapse offers short-term advantages compared with operations performed by laparotomy. The aim of this prospective study was to report technical and functional outcome after laparoscopic rectopexy to the promontory in consecutive patients operated on by a single surgeon. PATIENTS AND METHODS: From May 1996 to July 2004, 54 consecutive patients (47 women), median age 53 years (range: 16-84 years), underwent laparoscopic rectopexy to the promontory for complete rectal prolapse. Preoperative evaluation included physical examination, dynamic videoproctography and, in patients with constipation, colonic transit time (with radiopaque markers). Postoperative evaluation included the same examinations and a simple global quality-of-life questionnaire. RESULTS: Conversion to laparotomy was required for three patients during the learning curve. Median duration of operation was 157 minutes (range: 50-370). There was no mortality and morbidity was 5.5% (brachial plexus palsy in two patients and urinary tract infection in one). Median hospital stay was 3.5 days (range: 1-11). There were 4 recurrences (7.4%). Functional outcome at 12 months showed the presence of constipation in 20.3% of patients (persistence in eight and de novo in three) and the presence of outlet obstruction in 25.9% of patients (persistence in six and de novo in eight). Anal continence improved in 72.4% of the 29 patients who complained of this symptom. The global quality-of-life questionnaire showed a satisfactory result in 96% of patients. CONCLUSION: Laparoscopic rectopexy to the promontory is a safe and efficient procedure to treat complete rectal prolapse; morbidity is low. Functional outcome is at least equivalent to that obtained with open procedures in terms of continence, constipation and outlet obstruction.

Stapled hemorrhoidectomy.
Stamos MJ
J Gastrointest Surg. 2006 May;10(5):627-8.

Stapled hemorrhoidectomy or "hemorrhoidopexy" has gained popularity for the treatment of grade 3-4 hemorrhoids, largely due to decreased pain as compared to traditional surgical hemorrhoidectomy. This decreased pain, along with proven short term efficacy, has been supported by numerous randomized controlled trials. Despite this evidence in support of stapled hemorrhoidectomy, controversy exists due to rare but occasionally life threatening complications, and also due to significant chronic pain experienced by a small but significant subset of patients. Attention to the technical details of the operation will limit these deleterious outcomes, and allow stapled hemorrhoidectomy to maintain it's niche role in the treatment of symptomatic hemorrhoids.

Obsessive-compulsive disorder and rectal prolapse.
Henry JB, Drummond LM, Kolb P
Eur J Gastroenterol Hepatol. 2006 Jul;18(7):797-798.

A 47-year-old woman with a long-standing history of obsessive-compulsive disorder relating to dirt and germs is presented. Her fear of developing bowel cancer led her to manually evacuate faeces from her rectum five times a day and to a resultant rectal prolapse. Treatment involved prolonged graduated exposure to the patient's feared contaminants and ritual avoidance. After 5 months of inpatient therapy, the patient reported a subjective 70% improvement in her symptoms. As her obsessive-compulsive disorder symptoms improved, the patient's rectal prolapse disappeared.

Lomas-Cooperman technique for rectal prolapse in the elderly patient.
Mansilla JE, Bannura GC, Contreras JP, Barrera AE, Melo CL, Soto DC
Tech Coloproctol. 2006 Jun;10(2):106-10. Epub 2006 Jun 19.

BACKGROUND: A variety of surgical procedures is used to correct complete rectal prolapse (RP). We analysed the immediate and long-term results of the Lomas-Cooperman technique in the management of symptomatic RP in elderly patients with severe concomitant diseases.METHODS: Across a 13-year period, all patients with RP having undergone surgery with this procedure were retrospectively evaluated. The technique consisted in placing a triply folded piece of polypropylene mesh encircling the anal canal through a perineal approach.RESULTS: A total of 22 patients (20 female) with a mean age of 84 years (range, 72-93 years) with severe concomitant pathologies were assessed. Four patients were classified as ASA II and 18 as ASA III. Mean Karnofsky score was 50%, ranging between 40% and 60%. All patients were operated on under regional anaesthesia without incidents. Mean operative time was 35 min(range, 20-60 min) and mean hospital stay was 4.5 days (range, 2-17 days). The most common immediate postoperative complication was urinary tract infection, found in 18% of the cases. Mean follow-up was 32 months (range, 4-84 months). During follow-up, 4 cases (18%) of mesh exteriorisation were detected, requiring mesh trimming at the outpatient clinic. Rectal prolapse recurred in 2 patients; one of them was managed with a new cerclage reaching a satisfactory outcome. Thus, by intention-to-treat basis, the recurrence rate was 4.5%. Constipation was resolved in three out of 4 patients, but in 18% of the cases late faecal impact was recorded. Mean preoperative incontinence score improved from 5.1+/-0.62 to 3.4+/-1.61 (p<0.0001) after surgery.CONCLUSION: Anal cerclage with the Lomas-Cooperman technique constitutes a simple and reproducible surgical technique with an acceptable morbidity and recurrence rate in high-risk elderly patients with RP.


Laparoscopic suture rectopexy in the treatment of persisting rectal prolapse in children : A preliminary report.

Koivusalo A, Pakarinen M, Rintala R
Surg Endosc. 2006 May 11;.

BACKGROUND: The repair of choice for persistent rectal prolapse (PRP) in children is disputed. Laparoscopic suture rectopexy (LSRP) is effective in adults, but its usefulness in pediatric PRP is unknown. We compared LSRP with posterosagittal rectopexy (PSRP). METHODS: Sixteen children, with a median age of 6.5 years (range, 0.8-16.8) and duration of symptoms of 2.8 years (range, 0.5-10.2), underwent surgery for PRP. Eight (1991-2000) had PSRP, and eight (2002-2005) had LSRP. Three patients with LSRP were healthy; the others had mental retardation and epilepsy (n = 1), cerebral palsy (n = 1), Aspeger's syndrome (n = 1), meningomyelocele (n = 1), and bladder extrophy (n = 1). Preoperative cologram (n = 6), sigmoideoscopy (n = 3), and anorectal manometry (n = 2) were normal in patients with LSRP. In LSRP, the rectum was mobilized and sutured to the sacral periosteum. RESULTS: Median operation time for LSRP was 80 min (range, 62-90) and for PSRP 40 min (range, 25-70) (p < 0.05); median hospital time was 6 days (range, 3-8) for LSRP and 6 days (range, 3-9) for PSRP (not significant). Six patients with LSRP had a median follow-up of 13 months (range, 4-24). None have had recurrences, and two patients (33%) require laxatives. Of the patients with PSRP, two (25%) had recurrence and underwent abdominal rectopexy with sigmoid resection. CONCLUSION: Medium-term results indicate that LSPR is effective in pediatric PRP. Constipation is the only postoperative problem in a significant proportion of patients.

Laparoscopic rectal prolapse surgery combined with short hospital stay is safe in elderly and debilitated patients.
Carpelan-Holmstrom M, Kruuna O, Scheinin T
Surg Endosc. 2006 May 13;.

BACKGROUND: We report the results of patients treated from January 2000 to June 2004 for full-thickness rectal prolapse with trans-abdominal surgery in Helsinki. METHODS: Sixty-five of 75 patients were treated laparoscopically, with a 6% conversion rate. Ten patients were operated on openly. Half of the patients were scored as American Society for Anesthesiologists III or IV. RESULTS: The operation time was similar in the laparoscopic and the open rectopexy procedures (p = 0.15), whereas laparoscopic resection rectopexy was more time-consuming compared to the open procedure (p = 0.007). Intraoperative bleeding during laparoscopic surgery was minimal in comparison to open surgery (p = 0.006). Patients treated laparoscopically had a shorter median hospital stay than those treated with an open procedure (rectopexy, 3 and 7 days, respectively; resection rectopexy, 4 and 7.5 days, respectively) (p < 0.00001). There was no mortality and minor morbidity. During follow-up, there were two prolapse recurrences. All surgical techniques improved fecal continence considerably. Eighty-four percent of rectopexy patients and 92% of resection rectopexy patients considered the surgical outcome to be excellent or good. CONCLUSIONS: Both rectopexy and resection rectopexy cure prolapse with good results and can be performed safely in older and debilitated patients. The laparoscopic approach enables a shortened hospital stay and is well tolerated in elderly patients.

Meta-analysis of flavonoids for the treatment of haemorrhoids.
Alonso-Coello P, Zhou Q, Martinez-Zapata MJ, Mills E, Heels-Ansdell D, Johanson JF, Guyatt G
Br J Surg. 2006 May 31;.

BACKGROUND:: The aim of the study was to evaluate the impact of flavonoids on those symptoms important to patients with symptomatic haemorrhoids. METHODS:: A comprehensive search strategy was used. All published and unpublished randomized controlled trials comparing any type of flavonoid to placebo or no therapy in patients with symptomatic haemorrhoids were included. Two reviewers independently screened studies for inclusion, retrieved all potentially relevant studies and extracted data. RESULTS:: Fourteen eligible trials randomized 1514 patients. Studies were of moderate quality and showed variability in the results with potential publication bias. Meta-analyses using random-effects models suggested that flavonoids decrease the risk of not improving or persisting symptoms by 58 per cent (relative risk (RR) 0.42 (95 per cent confidence interval (c.i.) 0.28 to 0.61)) and showed an apparent reduction in the risk of bleeding (RR 0.33 (95 per cent c.i. 0.19 to 0.57)), persistent pain (RR 0.35 (95 per cent c.i. 0.18 to 0.69)), itching (RR 0.65 (95 per cent c.i. 0.44 to 0.97)) and recurrence (RR 0.53 (95 per cent c.i. 0.41 to 0.69)). CONCLUSION:: Limitations in methodological quality, heterogeneity and potential publication bias raise questions about the apparent beneficial effects of flavonoids in the treatment of haemorrhoids.

A prospective audit of early pain and patient satisfaction following out-patient band ligation of haemorrhoids.
Watson NF, Liptrott S, Maxwell-Armstrong CA
Ann R Coll Surg Engl. 2006 May;88(3):275-9.

INTRODUCTION: Information regarding early morbidity, pain and patient satisfaction following band ligation of haemorrhoids is limited. This is the first report to address these issues specifically.PATIENTS AND METHODS: A total of 183 patients underwent the procedure over a 10-month period. Prospective data were collected using a detailed structured questionnaire regarding symptoms, analgesia requirements and patient satisfaction in the following week.RESULTS: The response rate was 74% (135/183). Pain scores were highest 4 h following the procedure. At 1 week, 75% of patients were pain-free, with 9 (7%) still experiencing moderate-to-severe pain. About 65% required oral analgesia, most frequently on the day of procedure. Rectal bleeding occurred in 86 patients (65%) on the day after banding, persisting in 32 (24%) at 1 week. Vaso-vagal symptoms occurred in 41 patients (30%) and were commonest at the time of banding. Eighty patients (59%) were satisfied with their experience and would undergo the procedure again. Patients requiring oral analgesia and those experiencing bleeding or vaso-vagal symptoms were significantly less likely to be satisfied with the procedure. Only 57% of the patients surveyed would recommend the procedure to a friend.CONCLUSIONS: Data from this large cohort of patients suggest that discomfort and bleeding may persist for a week or more following banding of haemorrhoids. Patients should be aware of this in order to make an informed decision as to whether to undergo the procedure, and surgeons should investigate ways of reducing it. Patient satisfaction may be further improved by more accurate counselling regarding the incidence of specific complications.

Red Hot Chili Pepper and Hemorrhoids: The Explosion of a Myth: Results of a Prospective, Randomized Placebo-Controlled Crossover Trial.
Altomare DF, Rinaldi M, La Torre F, Scardigno D, Roveran A, Canuti S, Morea G, Spazzafumo L
Dis Colon Rectum. 2006 May 19;.

PURPOSE: Spicy foods are appreciated by a large part of the world population but have been blamed for causing hemorrhoids or exacerbating their symptoms, although no epidemiologic studies have been performed supporting this hypothesis. In this double-blind, randomized, placebo-controlled, crossover trial, we have studied the effects of a single dose of red hot chili pepper on the hemorrhoidal symptoms. METHODS: Fifty patients with second-degree and third-degree symptomatic hemorrhoids were randomly assigned to take a capsule containing red hot chili powder or placebo during lunch, scoring five hemorrhoidal symptoms (bleeding, swelling, pain, itching, and burning) on a visual analog scale. After one week, crossover treatment was administered according to the same methodology. Other treatments and foods potentially related with anorectal symptoms were discontinued during the study periods. RESULTS: Patients assigned low scores to their hemorrhoidal symptoms before the study and the scores remained unchanged during the 48 hours after both placebo and chili pepper treatment, the latter showing no statistically significant effects. CONCLUSIONS: There is no scientific evidence that a spicy meal based on red hot chili pepper may worsen hemorrhoidal symptoms and, therefore, there is no reason to prevent these patients from occasionally enjoying a spicy dish if they so wish.

Longitudinal multiple rubber band ligation: an alternative method to treat mucosal prolapse of the anterior rectal wall.
Kleinubing H Jr, Pinho MS, Ferreira LC
Dis Colon Rectum. 2006 Jun;49(6):876-8.

PURPOSE: The aim of this study is to present a new approach for the treatment of mucosal prolapse of the anterior rectal wall using a multiple longitudinal rubber band ligation procedure. METHODS: The therapeutic approach using multiple longitudinal rubber band ligations on anterior rectal wall was undertaken in 17 patients after failure of conventional medical treatment. RESULTS: Double rubber band ligation was undertaken in seven patients and triple ligation in nine patients. In a median follow up of 12 months fourteen patients (87.5 percent) showed complete and persistent remission of symptoms. Two patients remained symptomatic and were treated by a second session of rubber band ligation which was succesful in one of them. No complications occured in this present series except in one patient with internal rectal prolapse patient who complained of persistent pain for seven days. CONCLUSIONS: These encouraging results have suggested this method as an effective alternative in the relief of this usually very symptomatic disorder.

Adaptation of the pursestring suture anoscope with a small hole in a case of stapled hemorrhoidectomy.
Yamamoto J, Nagai M, Smith TB, Tamaki S, Kubota T, Sasaki K, Ohmori T, Maeda K
Dis Colon Rectum. 2006 Jun;49(6):925-6.

PURPOSE: Stapled hemorrhoidectomy has become more popular with the general surgeon, mainly because of reduced postoperative pain and shorter hospital stays. However, we have faced some complications caused byirregular pursestring suture of the rectal mucosa. METHODS: To secure pursestring suture in the rectal mucosa layer, we placed a small hole in the Pursestring Suture Anoscope. RESULTS: Since 2001, we have experienced more than 200 cases of stapled hemorrhoidectomy and in the last two years we have performed pursestring suture by using a Pursestring Suture Anoscope with a small hole in 60 cases. Rectal mucosa was resected without irregular defect in all the cases. CONCLUSIONS: Stapled hemorrhoidectomy can be performed easily and safely with this modification.


[The solitary rectal ulcer syndrome.]
Meurette G, Regenet N, Frampas E, Sagan C, Le Borgne J, Lehur PA
Gastroenterol Clin Biol. 2006 Mar;30(3):382-90.

The solitary rectal ulcer syndrome is a rare debilitating disorder of the rectum characterized by perianal chronic pain with passage of blood and mucus. The pathogenesis remains uncertain, rectal prolapse and trauma from straining are the main hypothesis. The diagnosis includes clinical symptoms associated with endoscopic lesion (erythema, ulcer or polypoid lesion) and histological features. Mano-metric studies and defecography are helpful to determinate an underlying defecation disorder or rectal prolapse. The treatment is controversial including a conservative option (medications and behavioural therapy) with poor long term results, and the surgical option (treatment of a rectal prolapse with or without resection of the lesion), more aggressive with uncertain results in a long follow-up period.

Longitudinal Multiple Rubber Band Ligation: An Alternative Method to Treat Mucosal Prolapse of the Anterior Rectal Wall.
Kleinubing H Jr, Pinho MS, Ferreira LC
Dis Colon Rectum. 2006 May 10;.

PURPOSE: The aim of this study is to present a new approach for the treatment of mucosal prolapse of the anterior rectal wall using a multiple longitudinal rubber band ligation procedure. METHODS: The therapeutic approach using multiple longitudinal rubber band ligations on anterior rectal wall was undertaken in 17 patients after failure of conventional medical treatment. RESULTS: Double rubber band ligation was undertaken in seven patients and triple ligation in nine patients. In a median follow up of 12 months fourteen patients (87.5 percent) showed complete and persistent remission of symptoms. Two patients remained symptomatic and were treated by a second session of rubber band ligation which was succesful in one of them. No complications occured in this present series except in one patient with internal rectal prolapse patient who complained of persistent pain for seven days. CONCLUSIONS: These encouraging results have suggested this method as an effective alternative in the relief of this usually very symptomatic disorder.

Doppler-Guided Hemorrhoidal Artery Ligation: An Alternative to Hemorrhoidectomy.
Jongen J, Peleikis HG
Dis Colon Rectum. 2006 May 1;.

Correct Indication for Ferguson's Hemorrhoidectomy.
Altomare DF
Dis Colon Rectum. 2006 May 11;.

Adaptation of the Pursestring Suture Anoscope With a Small Hole in a Case of Stapled Hemorrhoidectomy.
Yamamoto J, Nagai M, Smith TB, Tamaki S, Kubota T, Sasaki K, Ohmori T, Maeda K
Dis Colon Rectum. 2006 May 2;.

PURPOSE: Stapled hemorrhoidectomy has become more popular with the general surgeon, mainly because of reduced postoperative pain and shorter hospital stays. However, we have faced some complications caused byirregular pursestring suture of the rectal mucosa. METHODS: To secure pursestring suture in the rectal mucosa layer, we placed a small hole in the Pursestring Suture Anoscope. RESULTS: Since 2001, we have experienced more than 200 cases of stapled hemorrhoidectomy and in the last two years we have performed pursestring suture by using a Pursestring Suture Anoscope with a small hole in 60 cases. Rectal mucosa was resected without irregular defect in all the cases. CONCLUSIONS: Stapled hemorrhoidectomy can be performed easily and safely with this modification.

Preoperative Anal Manometry Predicts Continence After Perineal Proctectomy for Rectal Prolapse.
Glasgow SC, Birnbaum EH, Kodner IJ, Fleshman JW, Dietz DW
Dis Colon Rectum. 2006 May 2;.

PURPOSE: This study examines whether preoperative anal manometry and pudendal nerve terminal motor latency predict functional outcome after perineal proctectomy for rectal prolapse. METHODS: All adult patients treated by perineal proctectomy for rectal prolapse from 1995 to 2004 were identified (N = 106). Forty-five patients underwent anal manometry and pudendal nerve terminal motor latency testing before proctectomy and they form the basis for this study. RESULTS: Perineal proctectomy with levatoroplasty (anterior 88.9 percent; posterior 75.6 percent) was performed in all patients, with a mean resection length of 10.4 cm. Four patients (8.9 percent) developed recurrent prolapse during a 44-month mean follow-up. Preoperative resting and maximal squeeze pressures were 34.2 +/- 18.3 and 60.4 +/- 30.5 mmHg, respectively. Pudendal nerve terminal motor latency testing was prolonged or undetectable in 55.6 percent of patients. Grade 2 or 3 fecal incontinence was reported by 77.8 percent of patients before surgery, and one-third had obstructed defecation. The overall prevalence of incontinence (77.8 vs. 35.6 percent, P < 0.0001) and constipation (33.3 vs. 6.7 percent, P = 0.003) decreased significantly after proctectomy. Patients with preoperative squeeze pressures >60 mmHg (n = 19) had improved postoperative fecal continence relative to those with lower pressures (incontinence rate, 10 vs. 54 percent; P = 0.004), despite having similar degrees of preoperative incontinence. Abnormalities of pudendal nerve function and mean resting pressures were not predictive of postoperative incontinence. CONCLUSIONS: Perineal proctectomy provides relief from rectal prolapse, with good intermediate term results. Preoperative anal manometry can predict fecal continence rates after proctectomy, because patients with maximal squeeze pressures >60 mmHg have significantly improved outcomes.

Disseminated Klebsiella pneumoniae infection after hemorrhoidectomy.
Chen WH, Yen JC, Kao YF
Int J Colorectal Dis. 2006 Apr 20;.


Solitary rectal ulcer: another view of the management algorithm.
Daniel F, Siproudhis L, Tohme C, Sayegh R
Gastrointest Endosc. 2006 Apr;63(4):738-9.

Experience of 3711 stapled haemorrhoidectomy operations (Br J Surg 2006; 93: 226-230).
Basso L, Cavallaro G, Polistena A
Br J Surg. 2006 Apr;93(4):507.

Impact of New Technologies on the Clinical and Functional Outcome of Altemeier's Procedure: A Randomized, Controlled Trial.
Boccasanta P, Venturi M, Barbieri S, Roviaro G
Dis Colon Rectum. 2006 Apr 4;.

PURPOSE: A randomized study was performed to assess whether new technologies offer advantages over the conventional technique on the clinical and functional outcome of patients with full-thickness rectal prolapse and fecal incontinence, submitted to Altemeier's procedure with levatorplasty. METHODS: Between January 1999 and December 2003, 58 patients (55 females; mean age, 70.9 +/- 11.3 years) with full-thickness rectal prolapse were evaluated with continence score, colonoscopy, anorectal manometry, anal electromyography, and sacral reflex latency; 40 of them were selected and randomly assigned to two groups: 20 patients (Group 1; 19 females, 73.4 +/- 10.4 years) were submitted to a conventional operation with monopolar electrocautery and handsewn anastomosis, and 20 (Group 2; 18 females, 71.5 +/- 12.2 years) using harmonic scalpel and circular stapler. Patients were followed up with clinical examination, anorectal manometry, and anal electromyography, with mean follow-up 29.3 +/- 8.5 and 27.5 +/- 9.2 months in Groups 1 and 2, respectively. RESULTS: Operative time, blood loss, and hospital stay were significantly reduced in Group 2 (P < 0.001), whereas no differences were found in pain score, time to return to normal activity, morbidity, and mortality. Complications were two (10 percent) stenosis in Group 1. Fecal continence score significantly improved in both groups (P < 0.01), whereas anorectal manometry and neurophysiologic data were not significantly modified by the operation. Recurrence rates were 15 and 10 percent in Groups 1 and 2, respectively (P= not significant). CONCLUSIONS: The clinical and functional long-term results of perineal rectosigmoidectomy with levatorplasty are not influenced by surgical instruments and type of coloanal anastomosis. The clinical relevance of the short-term results in high-risk patients should be specifically investigated.

Biofeedback therapy for rectal intussusception.
Hwang YH, Person B, Choi JS, Nam YS, Singh JJ, Weiss EG, Nogueras JJ, Wexner SD
Tech Coloproctol. 2006 Mar 15;.

BACKGROUND: Surgery for isolated internal rectal intussusception is controversial due to high morbidity. Therefore, there is interest in other forms of treatment that are safe and effective. The aim of this study was to determine outcome and identify predictors for success of biofeedback therapy in patients with rectal intussusception. METHODS: We retrospectively evaluated the results of electromyography (EMG)-based biofeedback in 34 patients with rectal intussusception without any other major pelvic floor or colonic physiologic disorder. RESULTS: A total of 34 patients (7 men) had undergone at least 2 biofeedback sessions. The patients had a mean age of 68.5 years (SD=11.4 years). In the 27 patients with constipation, the frequency of weekly spontaneous bowel movements (mean+/-SD) was 2.0+/-6.8 before and 4.1+/-4.6 after biofeedback (p<0.05). The frequency of weekly assisted bowel movements decreased from 3.8+/-3.5 before to 1.5+/-2.2 after therapy (p<0.005). The number of patients who experienced incomplete evacuation decreased from 17 (63%) to 9 (33%) (p<0.05). Thirty-three percent of patients had complete resolution of the symptoms, 19% had partial improvement, and 48% had no improvement. Patients with constipation lasting less than nine years had a 78% success rate vs. 13% in patients who were consti- pated more than 9 years (p<0.01). In seven patients with incontinence, the frequency of daily incontinence episodes decreased from 1.0+/-0.7 before to 0.07+/-0.06 after biofeedback (p<0.05). The fecal incontinence score decreased from 13.1+/-4.2 before to 4.6+/-3.6 after treatment (p<0.005). Two patients (29%) were completely continent following biofeedback, 2 had partial improvement, and 3 (43%) had no significant improvement. There was no mortality in either group. CONCLUSIONS: Biofeedback is a safe and effective treatment option for constipation and fecal incontinence due to rectal intussusception in patients who are willing to complete the course of treatment. Long-standing constipation is less effectively cured by biofeedback.

PPH03 stapled hemorrhoidopexy: our experience.
Lim YK, Eu KW, Ho KS, Ooi BS, Tang CL
Tech Coloproctol. 2006 Mar 15;.

BACKGROUND: Stapled hemorrhoidopexy is an established treatment for hemorrhoidal disease. We evaluated our experience with stapled hemorrhoidopexy using the new Procedure for Prolapse and Hemorrhoids (PPH03) Proximate HCS hemorrhoidal circular stapler (Ethicon Endo-Surgery). METHODS: We retrospectively reviewed clinical data for 238 patients who had undergone stapled hemorrhoidopexy in our department over a 2-month period. Patients were followed-up for a median of 3.5 weeks (range, 1-11 weeks) and were analyzed for complications and resolution of symptoms. RESULTS: The hemorrhoids treated were third- and fourth-degree, as well as second degree (after failure of other therapies). Mean duration of surgery was 12.7 minutes (range, 5-20 minutes) and the majority of patients was treated with an ambulatory procedure. Most patients were discharged within 6 hours after surgery. On follow-up, 3.7% of patiets had minor complaints after surgery. Technically, the new PPH03 stapler device has a quickclose knob, which allows rapid opening and closing. The closed staple height of 0.75 mm increases staple line compression on tissue and key blood vessels, hence minimizing bleeding. Prior to this, stapled hemorrhoidopexy was done using the PPH01 device. CONCLUSIONS: Stapled hemorrhoidopexy using the new PPH03 stapler is a safe, short and effective procedure in the management of hemorrhoids. It can be done in the ambulatory setting and patients have few postoperative complications.

Long-term results after stapled haemorrhoidopexy for third-degree haemorrhoids.
Kanellos I, Zacharakis E, Kanellos D, Pramateftakis MG, Tsachalis T, Betsis D
Tech Coloproctol. 2006 Mar 15;.

BACKGROUND: Stapled haemorrhoidopexy (SH) is associated with low postoperative pain but, when performed for advanced piles, carries high recurrence rates. The aim of our study was to assess our long-term results after SH for third-degree haemorrhoids. METHODS: A total of 126 consecutive patients (67 men and 59 women) with third-degree haemorrhoids underwent SH in our unit between 1998 and 2002. Of these, 120 (95.2%) were followed up in the outpatient department after a median interval of 61.5 months (range, 38-84 months). RESULTS: During the postoperative period, 7 patients (5.8%) experienced pain for 5-12 days, which was treated with oral analgesia. Seven patients (5.8%) experienced gas incontinence and one of them also reported soiling; the incontinence subsided within 2-8 weeks. Recurrence of the haemorrhoidal disease occurred in 8 patients (6.6%). CONCLUSIONS: SH is a safe, low-pain and, in the long-term, effective technique for the treatment of third-degree haemorrhoids.


Risk factors associated with hemorrhoidal symptoms in specialized consultation.
Pigot F, Siproudhis L, Allaert FA
Gastroenterol Clin Biol. 2005 Dec;29(12):1270-4.

Epidemiology and risk factors of hemorrhoidal disease are not well defined. AIMS AND METHODS: Past history and events occurring during the last two weeks before a medical visit for acute hemorrhoidal symptoms were analyzed and compared with controls consulting for any other diagnosis without exclusion. RESULTS: Among complete inquiries returned by 931 private gastroenterologists, files from 1033 patients (542 males) and 1028 controls (504 males) were randomly selected. Hemorrhoidal disease patients were younger (47 +/- 14.5 vs. 52 +/- 16.5 yrs; P<0.0001); sex ratio was not different from controls. Factors significantly associated with hemorrhoidal crisis were: past history of hemorrhoidal symptoms, age<50 yrs, past history of anal fissure, occupational activity (OR 5.17; 1.95; 1.72; 1.43; P<0.1) and recent unusual events: spicy diet, constipation, physical activity, alcohol intake (OR 4.95; 3.93; 2.79; 1.99; P<0.1). Stress protected against hemorrhoids (OR 0,49; P<0.0001). For women aged less than 40 yrs, no significant risk factor related with genital activity was found for hemorrhoidal disease. CONCLUSION: For young patients, especially those with a past hemorrhoidal history, spice or alcohol intake and constipation are risk factors for hemorrhoidal crisis. For young women, prevention is essentially based on treatment of constipation associated with genito-obstetrical events.

Opinions and Facts on Reinterventions After Complicated or Failed Stapled Hemorrhoidectomy.
Dis Colon Rectum. 2006 Feb 21;.

Pathophysiology and Role of Biofeedback Therapy in Solitary Rectal Ulcer Syndrome.
Rao SS, Ozturk R, De Ocampo S, Stessman M
Am J Gastroenterol. 2006 Feb 8;.

BACKGROUND: Solitary rectal ulcer syndrome (SRUS) is a behavioral disorder whose pathophysiology is incompletely understood. Likewise, its treatment, particularly the role of biofeedback therapy (BT) is unclear. AIM: To evaluate anorectal function and morphology and to assess efficacy of BT. METHODS: Eleven patients (8f) with refractory SRUS underwent symptom assessments, anorectal manometry, defecography, balloon expulsion test, and sigmoidoscopy. Physiological tests were also performed in 15 (11f) healthy controls. Subsequently, SRUS patients underwent biofeedback treatment. Symptoms and manometry were reassessed. RESULTS: Nine (82%) patients exhibited dyssynergia ( p < 0.001). Rectal sensory thresholds were decreased (p < 0.04). After biofeedback, straining effort and stool frequency decreased ( p < 0.05), and bowel satisfaction score (VAS) improved ( p < 0.001). Digital maneuvers were discontinued by all five patients and bleeding stopped in 56%. The defecation index increased ( p < 0.05), dyssynergia normalized, and balloon expulsion time decreased ( p < 0.05). There was complete healing in 4 (36%), >/=50% healing in 2 (18%), and <50% healing in 4 (36%) patients. CONCLUSIONS: SRUS associated with excessive straining, digital disimpaction, rectal hypersensitivity, dyssynergic defecation, and prolonged evacuation. BT may improve symptoms and anorectal function and facilitate healing.

Stapled vs open hemorrhoidectomy: long-term outcome of a randomized controlled trial.
Picchio M, Palimento D, Attanasio U, Renda A
Int J Colorectal Dis. 2006 Feb 15;.

BACKGROUND AND AIMS: Stapled hemorrhoidectomy is a relatively new procedure, and studies on long-term outcomes are few. We present the results of a 5-year follow-up on patients recruited to a randomized controlled trial comparing stapled and Milligan-Morgan hemorrhoidectomy. PATIENTS AND METHODS: We performed telephone interviews and office visits between May and July 2005 on patients who had taken part in a randomized controlled trial from May 1999 to December 2000. RESULTS: Occasional pain and bleeding were referred by the patients with no difference between the two groups. The patients were also equally satisfied with both procedures. No recurrent hemorrhoidal prolapse or stenosis was detected at anorectal exploration and rigid sigmoidoscopy. CONCLUSION: Both stapled and Milligan-Morgan techniques guarantee satisfactory long-term results. Larger studies are needed to assess the durability of stapled hemorrhoidectomy.

Strangulation of internal hemorrhoids complicating sclerosing therapy with injection of OC-108 (Zione).
Hachiro Y, Kunimoto M, Abe T, Muraki S, Kusano M
Int J Colorectal Dis. 2006 Feb 9;:1-2.

Mesh invasion of the rectum: an unusual late complication of rectal prolapse repair.
Karagulle E, Yildirim E, Turk E, Akkaya D, Moray G
Int J Colorectal Dis. 2006 Mar 7;.

Various surgical techniques have been described for repair of rectal prolapse; however, there is no agreement on a standard treatment method. In the Ripstein procedure, the rectum is fixed to the sacrum with a piece of mesh material. We describe the case of a patient who had undergone a Ripstein procedure to address rectal prolapse 6 years before admission to our clinic. His complaints were anal discomfort, abdominal discomfort, and tenesmus of 2 years duration. Rectoscopy and abdominal computed tomography (CT) revealed that the mesh had penetrated the rectal wall and was located within the rectal lumen 7-8 cm from the anal verge. Once the mesh was endoscopically, and the patient's symptoms resolved completely. Various complications of mesh implantation for rectal prolapse repair have been documented, but rectal wall penetration has not been reported to date. This report presents our case of this unusual complication and reviews the relevant literature.

Management of Recurrent Rectal Prolapse: Surgical Approach Influences Outcome.
Steele SR, Goetz LH, Minami S, Madoff RD, Mellgren AF, Parker SC
Dis Colon Rectum. 2006 Feb 13;.

INTRODUCTION: Recurrent rectal prolapse is an unresolved problem and the optimal treatment is debated. This study was designed to review patterns of care and outcomes in a large cohort of patients after surgery for recurrent prolapse. METHODS: From 685 patients who underwent operative repair for full-thickness external rectal prolapse, we identified 78 patients (70 females; mean age, 66.9 years) who underwent surgery for recurrence. We reviewed the subsequent management and outcomes for these 78 patients. RESULTS: Mean interval to their first recurrence was 33 (range, 1-168) months. There were significantly more re-recurrences after reoperation using a perineal procedure (19/51) compared with an abdominal procedure (4/27) for their recurrent rectal prolapse (P = 0.03) at a mean follow-up of nine (range, 1-82) months. Patients undergoing abdominal repair of recurrence were significantly younger than those who underwent perineal repair (mean age, 58.5 vs. 71.5 years; P < 0.01); however, there was nosignificant difference between the two groups with regard to the American Society of Anesthesiologists classification (P = 0.89). Eighteen patients had surgery for a second recurrence, with perineal repairs associated with higher failure rates (50 vs. 8 percent; P = 0.07). Finally, when combining all repairs, the abdominal approach continued to have significantly lower recurrence rates (39 vs. 13 percent; P < 0.01). CONCLUSIONS: The re-recurrence rate after surgery for recurrent rectal prolapse is high, even at a relatively short follow-up interval. Our data suggest that abdominal repair of recurrent rectal prolapse should be undertaken if the patient's risk profile permits this approach.

Randomized controlled trial of LigaSure with submucosal dissection versus ferguson hemorrhoidectomy for prolapsed hemorrhoids.
Wang JY, Lu CY, Tsai HL, Chen FM, Huang CJ, Huang YS, Huang TJ, Hsieh JS
World J Surg. 2006 Mar;30(3):462-6.

INTRODUCTION: The aim of this study was to compare the outcomes between the LigaSure vessel sealing system and the conventional closed Ferguson hemorrhoidectomy procedure performed by diathermy. METHODS: A series of 84 patients with grades III and IV hemorrhoids were randomized into two groups: (1) LigaSure hemorrhoidectomy with submucosal dissection (42 patients) and (2) Ferguson hemorrhoidectomy (42 patients). The patient demographics, operative details, parenteral analgesic requirement, postoperative pain score (assessed by an independent assessor), operating time, intraoperative blood loss, hospital stay, early and delayed complications, and time off from work or normal activity were recorded. The patients were regularly followed up at 1, 2, 4, 6, and 8 weeks after surgery. RESULTS: There were no statistically significant differences between the two groups in terms of age, gender, duration of symptoms, grade of the hemorrhoid(s), or number of hemorrhoids resected. The mean operating time for LigaSure hemorrhoidectomy with submucosal dissection was significantly shorter than that for the Ferguson hemorrhoidectomy (11.3 +/- 0.4 vs. 34.2 +/- 0.7 minutes; P < 0.0001). Patients treated with the LigaSure method had significantly less blood loss (P < 0.0001), a better pain score (P < 0.0001), less parenteral analgesic requirement (P < 0.0001), shorter hospital stay (P < 0.0001), and less time off from work or normal activity (P < 0.0001). There was no difference in the early and delayed postoperative complications between the two groups. CONCLUSIONS: LigaSure hemorrhoidectomy with submucosal dissection is a safe, effective procedure for grade III and IV hemorrhoids. Patients derive greater short-term benefits: reduced intraoperative blood loss, operating time, and postoperative pain as well as earlier resumption of work or normal activity. Long-term follow-up with a larger number of patients is required to confirm the long-term results of this procedure.


Fiber for the treatment of hemorrhoids complications: a systematic review and meta-analysis.

Alonso-Coello P, Mills E, Heels-Ansdell D, Lopez-Yarto M, Zhou Q, Johanson JF, Guyatt G
Am J Gastroenterol. 2006 Jan;101(1):181-8.

OBJECTIVES: To evaluate the impact of laxatives on a wide range of symptoms in patients with symptomatic hemorrhoids. METHODS: We searched using the following sources: MEDLINE, EMBASE, CINAHL and CENTRAL, BIOSIS, AMED, Papers First and Proceedings; study authors, industry, and experts in the field. We included all published and unpublished parallel group randomized controlled trials comparing any type of laxative to placebo or no therapy in patients with symptomatic hemorrhoids. Two reviewers independently screened studies for inclusion, retrieved all potentially relevant studies, and extracted data on study population, intervention, prespecified outcomes, and methodology. RESULTS: Seven trials randomized 378 patients to fiber or a nonfiber control. Studies were of moderate quality for most outcomes. Meta-analyses using random effects models suggested that fiber has an apparent beneficial effect. The risk of not improving/persisting symptoms decreased by 47% in the fiber group (RR = 0.53, 95% CI 0.38-0.73) and the risk of bleeding by 50% (RR = 0.50, 95% CI 0.28-0.89). Studies with multiple follow-ups, usually at 6 wk and at 3 months, showed consistent results over time. Results are also compatible with large treatment effects in prolapse, pain, and itching, but even in the pooled analyses confidence intervals were wide and compatible with no effect (RR = 0.79, 95% CI 0.37-1.67; RR = 0.33, 95% CI 0.07-1.65; and RR = 0.71, 95% CI 0.24-2.10, respectively). One study suggested a decrease in recurrence. Results showed a nonsignificant trend toward increases in mild adverse events in the fiber group (RR = 6.0, 95% CI 0.57-64.8). CONCLUSIONS: Trials of fiber show a consistent beneficial effect for symptoms and bleeding in the treatment of symptomatic hemorrhoids.

First 100 Cases With Doppler-Guided Hemorrhoidal Artery Ligation.
Greenberg R, Karin E, Avital S, Skornick Y, Werbin N
Dis Colon Rectum. 2006 Jan 31;.

PURPOSE: This study was designed to examine the benefits of a Doppler-guided hemorrhoidal artery ligation technique in terms of surgical outcome, functional recovery, and postoperative pain. METHODS: Using local, regional, or general anesthesia, 100 patients with symptomatic Grades II or III hemorrhoids underwent sonographic identification and suture ligation of six to eight terminal branches of the superior rectal artery above the dentate line. Visual Analog Scales were used for postoperative pain scoring. Surgical and functional outcomes were assessed at 6 weeks and 3, 6, and 12 months after surgery. RESULTS: There were 42 (42 percent) males and 58 (58 percent) females (mean age, 42 years; median duration of symptoms, 6.3 years). The mean operative time was 19 minutes. Local anal block combined with intravenous sedation (n = 93) or general or spinal (n = 7) anesthesia was used. Only five were hospitalized overnight. There was no urinary retention, bleeding, or mortality in the immediate postoperative course. The mean pain score decreased from 2.1 at two hours postoperative to 1.3 on the first postoperative day. All patients had a complete functional recovery by the third postoperative day. Ninety-four patients remained asymptomatic after a mean follow-up of six months: four patients required additional surgical excision, and two required rubber band ligations for persistent bleeding. On follow-up, there was no report of incontinence to gas or feces, fecal impaction, or persistent pain. CONCLUSIONS: Our experience indicates that Doppler-guided hemorrhoidal artery ligation is safe and effective and can be performed as an outpatient procedure with local or regional anesthesia and with minimal postoperative pain and early recovery.

Doppler-guided hemorrhoidal artery ligation.
Scheyer M, Antonietti E, Rollinger G, Mall H, Arnold S
Am J Surg. 2006 Jan;191(1):89-93.

BACKGROUND: In 1995, Morinaga reported a new technique for the treatment of hemorrhoids, hemorrhoidal artery ligation (HAL), which uses a specially designed proctoscope coupled with a Doppler transducer for identification and ligation of hemorrhoidal arteries. METHODS: Because the arteries carrying the blood inflow are ligated, internal pressure of the plexus hemorrhoidalis is decreased. RESULTS: We report the results of the first 308 patients (189 male and 119 female; median age 50.1 years) who have been treated at our department since 2002 and followed-up for a median period of 18 months. Eighty-nine patients had grade II, 192 patients had grade III, and 27 patients had grade IV hemorrhoids. The acute symptoms of hemorrhoids were treated immediately by performing HAL. CONCLUSIONS: Our study showed that HAL is painless, effective, and has a low rate of complications. It can be applied in an outpatient setting and is an good alternative to all other hemorrhoid treatment methods.

Improvement of wound healing after hemorrhoidectomy: a double-blind, randomized study of botulinum toxin injection.
Patti R, Almasio PL, Muggeo VM, Buscemi S, Arcara M, Matranga S, Di Vita G
Dis Colon Rectum. 2005 Dec;48(12):2173-9.

PURPOSE: Hemorrhoidectomy is usually associated with significant pain during the postoperative period. The spasm of the internal sphincter seems to play an important role in the origin of pain. This study was designed to evaluate the effectiveness of intrasphincter injection of botulinum toxin after hemorrhoidectomy in reducing the maximum resting pressure of the anal canal, accelerating wound healing, and decreasing postoperative pain when resting and during defecation. METHODS: Thirty patients with hemorrhoids of third and fourth degree were included in the study and randomized in two groups. Anorectal manometry was performed preoperatively and 5 and 30 days afterward in all patients undergoing Milligan-Morgan hemorrhoidectomy. One group received an injection of 0.4 ml of saline into the internal anal sphincter, the other group were injected with 0.4 ml of solution containing 20 units of botulinum toxin. RESULTS: After five days from hemorrhoidectomy, maximum resting pressure decreased in the group injected with botulinum toxin and increased in the placebo group. The time of healing and postoperative pain when resting and during defecation significantly decreased in the group treated with an injection of botulinum toxin. CONCLUSIONS: Botulinum toxin injection into internal anal sphincter after hemorrhoidectomy is effective in reducing maximum resting pressure, time of healing, and postoperative pain both on resting and during defecation in absence of complications or side effects.

Solitary rectal ulcer syndrome associated with ulcerative colitis.
Uza N, Nakase H, Nishimura K, Yoshida S, Kawabata K, Chiba T
Gastrointest Endosc. 2006 Feb;63(2):355-356.