G. Terrosu - Società Triveneta di Chirurgia

AZIENDA
AZIENDA OSPEDALIERO-UNIVERSITARIA
OSPEDALIERO-UNIVERSITARIA S.M.
S.M. della
della MISERICORDIA
MISERICORDIA -UDINE
UDINE
CLINICA
CLINICA CHIRURGICA
CHIRURGICA GENERALE
GENERALE
Direttore:
Direttore: Prof.
Prof. F.
F. BRESADOLA
BRESADOLA
QUARTE
QUARTE GIORNATE
GIORNATE RODIGINE
RODIGINE DI
DI
COLOPROCTOLOGIA
COLOPROCTOLOGIA
Chirurgia
Chirurgia retto-anale:
retto-anale: Opinioni
Opinioni ee Confronti
Confronti
ROVIGO
ROVIGO 99 -- 10
10 OTTOBRE
OTTOBRE 2008
2008
Il punto sulla malattia emorroidaria
Giovanni Terrosu
Quando una mucoprolassectomia
1.
1. Prolasso
Prolasso muco-emorroidario
muco-emorroidario 2°
2°-3°grado
-3°grado sintomatico
sintomatico
2.
2. Prolasso
Prolasso circonferenziale
circonferenziale
Nelle
Nelle emorroidi
emorroidi di
di III
III grado
grado sintomatiche
sintomatiche ritieni
ritieni che
che possa
possa
essere
essere indicata
indicata la
la prolassectomia
prolassectomia::
1.
’è prolasso
1. Quando
Quando cc’è
prolasso circonferenziale
circonferenziale
2.
2. Quasi
Quasi mai
mai
3.
°))
3. Sempre
Sempre (anche
(anche solo
solo 22 gavoccioli
gavoccioli di
di 22°
Consensus
Consensus Conference
Conference "La
"La malattia
malattia Emorroidaria“
Emorroidaria“
G.
G. Casula,
Casula, V.
V. Pezzangora,
Pezzangora, G.
G. Rispoli,
Rispoli, G.
G. Leoni,
Leoni, A.
A. Miro
Miro
108°SIC,
Roma
16-18
ottobre
2006
108°SIC, Roma 16-18 ottobre 2006
100
Sala
Sala
80
60
44,86
33,64
40
21,5
20
0
1
100,00
3
Esperti
Esperti
80,00
60,00
2
50,00
43,18
40,00
20,00
0,00
6,82
1
2
3
Attuali spazi della chirurgia tradizionale
1.
1. (4°
(4°?)
?) grado
grado sintomatiche
sintomatiche
2.
2. 3°grado
3°grado aa pacchetti
pacchetti separati
separati sintomatiche
sintomatiche
3.
3. Ragade
Ragade ±± ipertono
ipertono associati
associati
4.
4. Discrepanza
Discrepanza di
di grado
grado tra
tra ii diversi
diversi pacchetti
pacchetti
Nelle emorroidi di III grado a pacchetti separati, in caso
d’indicazione chirurgica , proponi più frequentemente:
1. Dearterializzazione con guida doppler
2. Emorroidectomia (Milligan-Morgan Classica, Radiofrequenza,
Ultrasuoni , etc.)
3. Prolassectomia
Consensus
Consensus Conference
Conference "La
"La malattia
malattia Emorroidaria“
Emorroidaria“
G.
Casula,
V.
Pezzangora,
G.
G. Casula, V. Pezzangora, G. Rispoli,
Rispoli, G.
G. Leoni,
Leoni, A.
A. Miro
Miro
108°SIC,
108°SIC, Roma
Roma 16-18
16-18 ottobre
ottobre 2006
2006
100
Sala
Sala
80
60
44,86
48,6
40
20
0
6,54
1
100
2
Esperti
Esperti
80
56,81
60
38,64
40
20
0
3
4,55
1
2
3
Il punto sull
’evidenze scientifiche
sull’evidenze
Practice
Practice parameters
parameters for
for the
the
management
management of
of haemorrhoids.
haemorrhoids.
by
by A.S.C.R.S.
A.S.C.R.S.
Cataldo
Cataldo et
et al.,
al., Dis
Dis Colon
Colon Rectum
Rectum
2005,
2005, 48,
48, 189
189
•• Medline
Medline 1990-2003
1990-2003
Hemorrhoidectomy
Hemorrhoidectomy should
should be
be reserved
reserved for
for patients
patients
refractory
refractory to
to office
office procedures,
procedures, unable
unable to
to tolerate
tolerate
office
office procedures,
procedures, patients
patients with
with large
large external
external
hemorrhoids
hemorrhoids or
or patients
patients with
with combined
combined internal
internal
and
and external
external hemorrhoids
hemorrhoids with
with significant
significant prolapse
prolapse
(grade
(grade III
III and
and IV).
IV).
Level
II
Level of
of evidence
evidence
Grade
B
Grade of
of recommendation
recommendation
B
Stapled
Stapled hemorrhoidopexy
hemorrhoidopexy is
is aa new
new alternative
alternative
available
available for
for individuals
individuals with
with significant
significant
hemorrhoidal
hemorrhoidal prolapse.
prolapse.
Il punto sull
’evidenze scientifiche
sull’evidenze
Stapled
Stapled versus
versus conventional
conventional surgery
surgery
for
for hemorrhoids
hemorrhoids (Review)
(Review)
S
S Jayaraman,
Jayaraman, Cochrane
Cochrane Database
Database Syst
Syst
Rev
Rev 2006
2006 oct
oct 18,
18, 44
Stapled
Stapled hemorrhoidopexy
hemorrhoidopexy is
is associated
associated with
with
aa higher
higher long-term
long-term risk
risk of
of hemorrhoid
hemorrhoid
recurrence
and the
the symptom
symptom of
of prolapse.
prolapse. ItIt
recurrence and
is
is also
also likely
likely to
to be
be associated
associated with
with aa higher
higher
likelihood
likelihood of
of long-term
long-term symptom
symptom recurrence
recurrence
and
and the
the need
need for
for additional
additional operations
operations
compared
compared to
to conventional
conventional excisional
excisional
hemorrhoid
hemorrhoid surgeries.
surgeries.
Patients
Patients should
should be
be informed
informed of
of these
these risks
risks
when
when being
being offered
offered the
the stapled
stapled
hemorrhoidopexy
hemorrhoidopexy as
as surgical
surgical therapy.
therapy.
IfIf hemorrhoid
hemorrhoid recurrence
recurrence and
and prolapse
prolapse are
are
the
the most
most important
important clinical
clinical outcomes,
outcomes, then
then
conventional
conventional excisional
excisional surgery
surgery remains
remains the
the
“gold
“gold standard”
standard” in
in the
the surgical
surgical treatment
treatment of
of
internal
internal hemorrhoids.
hemorrhoids.
Stapled
Stapled hemorrhoidopexy
hemorrhoidopexy is
is associated
associated with
with aa higher
higher long-term
long-term recurrence
recurrence
rate
rate
of
of internal
internal hemmorrhoids
hemmorrhoids compared
compared with
with conventional
conventional excisional
excisional
hemorrhoid
hemorrhoid surgery
surgery
Comparison or Outcome
No. Studies
No. Participants
Odds Ratio (95% CI)
P Value
No hemorrhoidal symptoms at final follow-up
7
563
0.65 [0.33, 1.29]
NS
5
513
0.68 [0.3, 1.53]
NS
9
6
2
8
6
4
2
5
4
699
533
136
798
628
273
136
274
211
1.3 [0.81, 2.08]
1.51 [0.76, 3.02]
0.86 [0.29, 2.54]
2.96 [1.33, 6.58]
2.68 [0.98, 7.34]
0.68 [0.16, 2.9]
0.59 [0.01, 36.25]
1.46 [0.55, 3.85]
0.9 [0.35, 2.34]
NS
NS
NS
0.008
0.05
NS
NS
NS
NS
3
224
1.09 [0.22, 5.31]
NS
3
7
5
5
156
513
377
503
1.16 [0.38, 3.58]
1.35 [0.61, 2.96]
1.28 [0.64, 2.55]
1.01 [0.31, 3.32]
NS
NS
NS
NS
Pain at follow-up >1 year but< 2 years
3
337
0.74 [0.35, 1.6]
NS
Recurrent internal hemorrhoids seen at final follow-up
7
537
3.85 [1.47, 10.07]
0.006
Recurrent hemorrhoids at follow-up >1 year but< 2 years 5
417
3.6 [1.24, 10.49]
0.02
3
412
0.52 [0.17, 1.52]
NS
7
668
1.57 [0.61, 4.05]
NS
No hemorrhoidal symptoms at follow-up >1 year but
<2 years
Hemorrhoidal bleeding at final follow-up
Bleeding at follow up >1 year but <2 years
Bleeding at follow-up >2 years
Hemorrhoidal prolapse at final follow-up
Prolapse at follow-up >1 year but <2 years
Pruritus ani at final follow-up
Pruritus ani at follow-up >2 years
Soiling or difficulty with hygiene or continence
Fecal urgency
Hygiene/continence problems at follow-up >1 year but
<2 years
Fecal urgency at follow-up >2 years
Skin tags at final follow-up
Skin tags at follow-up >1 year but <2 years
Pain related to hemorrhoids at final follow-up
Difficulty voiding because of outlet obstruction or anal
stenosis
Further surgeries
S.
S. Jayaraman,
Jayaraman, Dis
Dis Colon
Colon Rectum
Rectum 2007;
2007; 50:
50: 1297–1305
1297–1305
Systematic
Systematic review
review and
and meta-analysis
meta-analysis of
of randomized
randomized controlled
controlled trials
trials
comparing
comparing stapled
stapled haemorrhoidopexy
haemorrhoidopexy with
with conventional
conventional
haemorrhoidectomy
haemorrhoidectomy
Test
Test for
for heterogeneity
heterogeneity
Comparison
Comparison or
or
No.
No. of
of
Outcome
Outcome
studies
studies pts.
pts.
Statistical
Statistical method
method
Effect
Effect size
size
PP
Total
Total complication
complication rate
rate
15
15
814
814
RR
RR (fixed),
(fixed), 95%
95% c.i.
c.i.
1·08
1·08 (0·80,
(0·80, 1·45)
1·45)
0·631
0·631
20·47
20·47
0·117
0·117 31·6
31·6
Postoperative
Postoperative haemorrhage
haemorrhage
25
25
1904
1904
RR
RR (fixed),
(fixed), 95%
95% c.i.
c.i.
1·57
1·57 (1·06,
(1·06, 2·33)
2·33)
0·023*
0·023*
11·64
11·64
0·976
0·976
Additional
Additional proc.
proc. for
for haemorrhage
haemorrhage 21
21
1559
1559
RR
RR (fixed),
(fixed), 95%
95% c.i.
c.i.
1·13
1·13 (0·64,
(0·64, 2·01)
2·01)
0·667
0·667
7·03
7·03
0·973
0·973 0·0
0·0
Requirement
Requirement for
for transfusion
transfusion
55
48
48
RR
RR (fixed),
(fixed), 95%
95% c.i.
c.i.
1·21
1·21 (0·35,
(0·35, 4·14)
4·14)
0·764
0·764
2·19
2·19
0·701
0·701 0·0
0·0
Sphincter
Sphincter damage
damage
16
16
901
901
RR
RR (random),
(random), 95%
95% c.i.
c.i.
2·52
2·52 (1·19,
(1·19, 5·32)
5·32)
0·016*
0·016*
76·35
76·35
<0·001
<0·001 81·7
81·7
Recurrent
Recurrent prolapse
prolapse (total)
(total)
21
21
1598
1598
RR
RR (fixed),
(fixed), 95%
95% c.i.
c.i.
2·29
2·29 (1·57,
(1·57, 3·33)
3·33)
<0·001*
<0·001* 10·16
10·16
0·750
0·750 0·0
0·0
<1
<1 year
year of
of follow-up
follow-up
77
420
420
RR
RR (fixed),
(fixed), 95%
95% c.i.
c.i.
2·93
2·93 (1·41,
(1·41, 6·07)
6·07)
0·004*
0·004*
6·13
6·13
0·294
0·294 18·5
18·5
11 year
year of
of follow-up
follow-up
14
14
1178
1178
RR
RR (fixed),
(fixed), 95%
95% c.i.
c.i.
2·07
2·07 (1·33,
(1·33, 3·20)
3·20)
0·001*
0·001*
4·10
4·10
0·848
0·848 0·0
0·0
Thrombosed
Thrombosed haemorrhoids
haemorrhoids
88
739
739
RR
RR (fixed),
(fixed), 95%
95% c.i.
c.i.
1·77
1·77 (0·89,
(0·89, 3·55)
3·55)
0·105
0·105
8·21
8·21
0·314
0·314 14·7
14·7
Persistent
Persistent wound
wound discharge
discharge
55
553
553
RR
RR (fixed),
(fixed), 95%
95% c.i.
c.i.
0·13
0·13 (0·06,
(0·06, 0·27)
0·27)
<0·001†
<0·001† 2·61
2·61
0·454
0·454
Anal
Anal stenosis
stenosis
18
18
1374
1374
RR
RR (fixed),
(fixed), 95%
95% c.i.
c.i.
1·00
1·00 (0·58,
(0·58, 1·71)
1·71)
1·000
1·000
13·11
13·11
0·286
0·286 16·1
16·1
Residual
Residual skin
skin tags
tags
14
14
1119
1119
RR
RR (fixed),
(fixed), 95%
95% c.i.
c.i.
1·56
1·56 (1·11,
(1·11, 2·20)
2·20)
0·011*
0·011*
13·08
13·08
0·288
0·288
Anal
Anal fissure
fissure
99
827
827
RR
RR (fixed),
(fixed), 95%
95% c.i.
c.i.
1·01
1·01 (0·42,
(0·42, 2·45)
2·45)
0·984
0·984
·19
·19
0·520
0·520 0·0
0·0
Acute
Acute urinary
urinary retention
retention
21
21
1703
1703
RR
RR (fixed),
(fixed), 95%
95% c.i.
c.i.
0·91
0·91 (0·67,
(0·67, 1·24)
1·24)
0·562
0·562
16·41
16·41
0·630
0·630 0·0
0·0
Faecaloma
Faecaloma
13
13
1116
1116
RR
RR (fixed),
(fixed), 95%
95% c.i.
c.i.
0·47
0·47 (0·27,
(0·27, 0·82)
0·82)
0·008†
0·008† 6·03
6·03
0·813
0·813 0·0
0·0
Pruritus
Pruritus
10
10
705
705
RR
RR (random),
(random), 95%
95% c.i.
c.i.
1·05
1·05 (0·49,
(0·49, 2·24)
2·24)
0·904
0·904
<0·001
<0·001 71·2
71·2
**Significantly
Significantly favours
favours conventional
conventional
No.
No. of
of
haemorrhoidectomy
haemorrhoidectomy
††Significantly
Significantly favours
favours stapled
stapled haemorrhoidopexy
haemorrhoidopexy
22
31·27
31·27
PP
I2
I2 (%)
(%)
0·0
0·0
0·0
0·0
15·9
15·9
W.J.
W.J. Shao,
Shao, British
British Journal
Journal of
of Surgery
Surgery 2008;
2008; 95:
95: 147–
147–
Systematic
Systematic review
review and
and meta-analysis
meta-analysis of
of randomized
randomized controlled
controlled trials
trials
comparing
comparing stapled
stapled haemorrhoidopexy
haemorrhoidopexy with
with conventional
conventional
haemorrhoidectomy
haemorrhoidectomy
Test
Test for
for heterogeneity
heterogeneity
Comparison
Comparison or
or
No.
No. of
of
No.
No. of
of
Outcome
Outcome
studies
studies pts.
pts.
Statistical
Statistical method
method
Operating
Operating time
time (min)
(min)
99
857
857
WMD
WMD (random),
(random), 95%
95% c.i.
c.i. −11·42
−11·42 (−18·26,−4·59)
(−18·26,−4·59)
0·001†
0·001† 819·57
819·57
Effect
Effect size
size
PP
22
PP
I2
I2 (%)
(%)
<0·001
<0·001
99·0
99·0
Inpatient
Inpatient stay
stay (days)
(days)
88
811
811
WMD
WMD (random),
(random), 95%
95% c.i.
c.i. −0·95
−0·95 (−1·32,−0·59)
(−1·32,−0·59)
<0·001†
<0·001† 104·80
104·80 <0·001
<0·001 93·3
93·3
Return
Return to
to normal
normal activity
activity (days)
(days)
10
10
998
998
WMD
WMD (random),
(random), 95%
95% c.i.
c.i. −11·75
−11·75 (−21·42,−2·08)
(−21·42,−2·08)
0·017†
0·017† 3724·23
3724·23 <0·001
<0·001 99·8
99·8
%
% satisfaction
satisfaction
77
572
572
RR
RR (fixed),
(fixed), 95%
95% c.i.
c.i.
0·003†
0·003† 2·99
2·99
0·810
0·810 0·0
0·0
Visual
Visual analogue
analogue scale
scale
33
287
287
WMD
WMD (random),
(random), 95%
95% c.i.
c.i. 0·40
0·40 (−0·29,
(−0·29, 1·09)
1·09)
0·254
0·254
0·125
0·125 51·9
51·9
During
During bowel
bowel movement
movement
44
485
485
SMD
SMD (fixed),
(fixed), 95%
95% c.i.
c.i.
<0·001†
<0·001† 20·48
20·48
24
24 hh after
after surgery
surgery
55
488
488
SMD
SMD (random),
(random), 95%
95% c.i.
c.i. −2·80
−2·80 (−4·25,−1·35)
(−4·25,−1·35)
<0·001†
<0·001† 119·62
119·62 <0·001
<0·001 96·7
96·7
1–2
1–2 weeks
weeks after
after surgery
surgery
44
425
425
SMD
SMD (random),
(random), 95%
95% c.i.
c.i. −1·58
−1·58 (−3·10,−0·06)
(−3·10,−0·06)
0·042†
0·042† 116·43
116·43 <0·001
<0·001 97·4
97·4
Analgesic
Analgesic consumption
consumption
77
655
655
SMD
SMD (random),
(random), 95%
95% c.i.
c.i. −2·98
−2·98 (−4·76,−1·20)
(−4·76,−1·20)
0·001†
0·001† 395·07
395·07 <0·001
<0·001 98·5
98·5
Incontinence
Incontinence (total)
(total)
18
18
1366
1366
RR
RR (fixed),
(fixed), 95%
95% c.i.
c.i.
0·71
0·71 (0·38,
(0·38, 1·35)
1·35)
0·298
0·298
3·74
3·74 0·
0· 809
809
0·0
0·0
<6
<6 months’
months’ follow-up
follow-up
33
120
120
RR
RR (fixed),
(fixed), 95%
95% c.i.
c.i.
n.e.
n.e.
n.e.
n.e.
n.e.
n.e.
n.e.
n.e.
n.e.
n.e.
66 months’
months’ follow-up
follow-up
15
15
1246
1246
RR
RR (fixed),
(fixed), 95%
95% c.i.
c.i.
0·71
0·71 (0·38,
(0·38, 1·35)
1·35)
0·298
0·298
3·74
3·74
0·809
0·809 0·0
0·0
RR
RR (random),
(random), 95%
95% c.i.
c.i.
1·94
1·94 (0·63,
(0·63, 5·95)
5·95)
0·246
0·246
19·86
19·86
0·031
0·031 49·6
49·6
Patient
Patient satisfaction
satisfaction
1·10
1·10 (1·03,
(1·03, 1·17)
1·17)
4·16
4·16
Pain
Pain score
score
Requiring
Requiring further
further surgery
surgery for
for recurrence
recurrence 11
11 750
750
**Significantly
Significantly favours
favours conventional
conventional
haemorrhoidectomy
haemorrhoidectomy
††Significantly
Significantly favours
favours stapled
stapled haemorrhoidopexy
haemorrhoidopexy
−0·44
−0·44 (−0·63,−0·26)
(−0·63,−0·26)
<0·001
<0·001 85·4
85·4
W.J.
W.J. Shao,
Shao, British
British Journal
Journal of
of Surgery
Surgery 2008;
2008; 95:
95: 147–160
147–160
Il punto sull
’evidenze scientifiche
sull’evidenze
Grado di raccomandazione
Tipo emorroidi
A
1°grado
B
C
Dieta e terapia
farmacologica
Legatura elastica
Scleroterapia
Fotocoagulazione
2°grado
Legatura elastica
HAL
THD
Emorroidopessi
Scleroterapia
3°grado
Emorroidopessi
Emorroidectomia
Hal
THD
Legatura elastica
Emorroidectomia
Emorroidopessi
4°grado
Singola
emorroide
esterna
D
Emorroidectomia
The
The treatment
treatment of
of hemorrhoids:
hemorrhoids: guidelines
guidelines of
of the
the Italian
Italian Society
Society of
of Colorectal
Colorectal Surgery.
Surgery.
Altomare
D.,
Roveran
A.,
Pecorella
G.,
Gaj
F.,
Stortini
E.
Altomare D., Roveran A., Pecorella G., Gaj F., Stortini E.
Tech
Tech Coloproctol.
Coloproctol. 2006
2006 Oct;10(3):181-6.
Oct;10(3):181-6.
Persistenza di malattia emorroidaria post Milligan
-Morgan:
Milligan-Morgan:
limite della procedura o errore tecnico?
1.
1. Limite
Limite della
della procedura
procedura (ponti)
(ponti)
2.
’operatore di
2. Scelta
Scelta dell
dell’operatore
di asportare
asportare solo
solo 11 oo 22 pacchetti
pacchetti
3.
3. Errore
Errore tecnico
tecnico se
se non
non legatura
legatura alta
alta
Come rimediare alle sequele delle Mucoprolassectomie?
1.
1. Persistenza/recidiva
Persistenza/recidiva prolasso:
prolasso: legatura
legatura oo MM
MM (THD?)
(THD?)
2.
2.
Rimozione
Rimozione di
di skin
skin tags
tags
3.
3. Granulomi:
Granulomi: asportazione
asportazione agraphes
agraphes
• 3 diatermy haemorrhoidectomy
• 1 excision
• 1 rubber band ligation
• 1 rubber band ligation
• 1 restapling
• 1 rubber band ligation
• 1 diathermy dissection
• 1 rubber band ligation
• 12 procedures (?)
• 3 diathermy dissection
• 3 diathermy haemorrhoidectomy, 3
rubber band ligation,
1 excision under
local anesthesia
• 2 rubber band ligation
• 5 diathermy hemorrhoidectomy
W.J.
W.J. Shao,
Shao, British
British Journal
Journal of
of Surgery
Surgery 2008;
2008; 95:
95: 147–160
147–160
Tecniche chirurgiche alternative:
sono supportate dalle evidenze scientifiche?
Autore
Anno
Studio
N. Paz.
Risoluzione
sintomi %
Follow-up
Morinaga
1995
/
116
78-96%
1
HAL
Sohn
2001
/
60
71-92%
/
THD
Shelygin
2003
/
102
82%
12
HAL
Lienert
2004
/
248
88%
/
HAL
CharùaGuindic
2004
Prospettico
49
100
4
/
Tagariello
2004
/
138
90%
/
THD
Felice
2005
/
68
73-94%
11 (3-18)
/
Ramirez
2005
/
32
78
18
/
Greenberg
2006
Prospettico
100
89%
3
HAL
Scheyer
2006
/
308
80%
18
HAL
Abdeldaim
2007
Prospettico
35
91.5%
18(12-24)
HAL
Dal Monte
2007
/
330
92%
46 (22-79)
THD
Walega
2007
/
507
84-92%
12
HAL
Wallis de Vries
2007
/
110
84%
8
HAL
Cantero
2008
Prospettico
50
83-97%
12
THD
Faucheron
2008
/
100
88%
36
HAL
Wilkerson
2008
Prospettico
113
86%
30
HAL
months
Tecnica
Tecniche chirurgiche alternative:
sono supportate dalle evidenze scientifiche?
Need for minor analgesics (doses)
Group A
hemorrhoidectomy
(n= 30)
11.7 12.6
Length of hospital postoperative stay (h)
62.9
29.0
19.8
Return to normal daily activities (days)
24.9
24.5
3.0
Early results
Evacuation problems
Group A
hemorrhoidectomy
(n= 30)
0
Stricture
Late results
Group B DG-HAL
(n= 30)
2.9
7.7
41.8
5.5
<0.005
<0.0001
<0.0005
Group B DG-HAL
(n= 30)
0
/
0
0
/
Incontinence
0
0
/
Failure (at 6°th week p.o.)
4 (13.3%)
5 (16.6%)
n.s.
Recurrent symptom (at 1 year)
4 (13.3%)
4 (13.3%)
n.s.
Comparison
Comparison of
of early
early and
and 1-year
1-year follow-up
follow-up results
results of
of
conventional
hemorrhoidectomy
and
hemorrhoid
conventional hemorrhoidectomy and hemorrhoid
artery
artery ligation:
ligation: aa randomized
randomized study
study
Bursics
A.
Bursics A.
Int
Int JJ Colorectal
Colorectal Dis
Dis (2004)
(2004) 19:176–180
19:176–180
In conclusion, both the closed scissors hemorrhoidectomy
and the DG-HAL procedure proved effective in treating
hemorrhoids in both the short and the long term. The 1-year
results of DG-HAL procedure do not differ from those of the
closed scissors hemorrhoidectomy. The short hospital stay,
the low complication rate, and the minimal postoperative
pain make the DG-HAL procedure ideal for 1-day surgery
and is in accordance with the requirements of minimally
invasive surgery.
Mucoprolassectomie e follow
-up:
follow-up:
è giunto il tempo di un bilancio?