A national evaluation of the management practices of hemorrhoidal disease in the Netherlands

  • Robin R. van Tol
  • Marieke P. A. Bruijnen
  • Jarno Melenhorst
  • Sander M. J. van Kuijk
  • Laurents P. S. Stassen
  • Stéphanie O. Breukink
Open Access
Original Article
  • 234 Downloads

Abstract

Purpose

In this study, we describe current practices in the management of hemorrhoidal disease in the Netherlands.

Methods

A validated online survey was performed among Dutch surgeons and residents treating hemorrhoidal disease. Contact details were retrieved from the Dutch Association for Surgery resulting in 619 contacts. Only doctors who were treating hemorrhoidal disease regularly were asked to complete the questionnaire. The following items were assessed: initial treatment, recurrence, complications, and follow-up.

Results

In total, 133 respondents completed the survey. Ninety percent of the respondents started with rubber band ligation (RBL) as the first treatment in low-grade hemorrhoidal disease. In case of recurrence, 64% of the respondents repeated RBL three times before switching to a more invasive treatment modality. In grade III hemorrhoidal disease, the respondents preferred more invasive techniques: a sutured hemorrhoidopexy was performed in 24%, Doppler-guided hemorrhoidal artery ligation (DG-HAL) in 9%, stapled hemorrhoidopexy in 19%, and the traditional hemorrhoidectomy in 31% of the patients, respectively. The majority of the respondents (39%) reported a mild complication in 5–10% of the patients. The most reported complication was pain. Nearly all the respondents (98%) reported a major complication in less than 5% of the patients. The majority of the patients (57%) were seen in outpatient clinics 6 weeks post-treatment.

Conclusion

This Dutch survey showed areas of common practice for primary treatment of hemorrhoidal disease. However, it also demonstrated varying practices regarding recurrent hemorrhoidal disease. Practical guidelines are required to support colorectal surgeons in the Netherlands.

Keywords

Hemorrhoids Survey Therapy Surgical Treatment algorithm 

Introduction

Hemorrhoidal disease is a common pathology with prevalence rates of up to 44% within the general population [1, 2, 3]. Hemorrhoids are usually classified by their location and by the presence and severity of prolapse. The most widely accepted classification is the Goligher classification [4]. Initial treatment of grades I–II hemorrhoidal disease is quite uniform. Conservative treatment including diet, lifestyle changes, and application of topical ointments is mostly offered as a first step [5, 6, 7]. In case of persistent symptoms, patients are usually treated with rubber band ligation (RBL) [8]. However, it is still unclear what the best next treatment modality is in case of recurrence after several failed RBL attempts.

Grades III and IV hemorrhoidal disease is often treated in a more invasive way, thereby skipping the first two steps. Similar to recurrence after RBL for grade I and II disease, there remains a debate what the best (surgical) treatment option is in case of recurrence.

Over the past two decades, knowledge of the anatomy of hemorrhoids has improved, leading to the introduction of new surgical technologies. This was accompanied by many studies comparing several surgical treatments including the Doppler-guided hemorrhoidal artery ligation (DG-HAL) with or without recto-anal repair (RAR) [9, 10, 11], a sutured hemorrhoidopexy [12, 13], the stapled hemorrhoidopexy (SH) [14, 15, 16], and the traditional hemorrhoidectomy [17, 18, 19, 20].

However, systematic reviews [21, 22] and guidelines [23, 24] including a Dutch guideline of Dunker et al. (published in a Dutch guideline database) highlighted the lack of a high level of evidence which is mandatory to develop an optimal treatment algorithm. Recently, two high-quality RCTs have been published [25, 26]. Results of these studies may not have been implemented in clinical practice yet.

Besides, as many studies use different outcomes assessing treatment effect, data of these studies cannot easily be compared or pooled into a single inference. As a result, it is difficult to determine what treatment yields the highest clinical benefit for each grade or what treatment is advocated in case of recurrence.

The aim of the present study was to assess current practice in (surgical) treatment of hemorrhoidal disease using a national survey among officially registered Dutch colorectal consultants, fellows, and residents in the Netherlands. Besides the complications for each treatment and outcome, parameters to determine treatment success were recorded.

Materials and methods

Design of the survey

Two surgical residents (RS, RT) formulated the questions of the survey. These questions were edited by a colorectal surgeon (SB). After making adjustments, the survey was reviewed by a second colorectal surgeon (LS).

The survey was created using a validated web-based program [27]. The survey consisted of 30 items: 13 multiple- choice questions, 14 optional questions, and three open-ended questions with a total word count of 1144 words. The questionnaire was developed in Dutch [see Appendix 1 for a version translated to English]. In order to check comprehensibility and content validity of the survey, several rounds of pilot testing were conducted before its actual distribution.

Survey distribution

We distributed the survey among officially registered Dutch colorectal consultants, fellows and residents. Contact details were retrieved from the Dutch Association for Surgery resulting in 619 contacts. Only doctors who were treating hemorrhoidal disease regularly at the time of the questionnaire, irrespective of the number of years of experience with the treatment, were asked to complete the questionnaire. A personalized e-mail with a link to the web-based survey was sent to each of them, and a reminder was sent 1 week later.

Data analysis

Only completed surveys were included in the analysis. Characteristics of the doctors, treatments used for primary and recurrent disease stratified by grade, and the outcome parameters were all described using absolute value and percentage. The complications were estimated as cumulative incidence.

All analyses were performed in IBM SPSS version 22.0.

Definitions

Conservative treatment consisted of diet, lifestyle changes, and application of topical ointments. Minimally invasive treatment consisted of laser therapy, Doppler-guided hemorrhoidal artery ligation (DG-HAL) (with recto-anal repair (RAR)) or a sutured hemorrhoidopexy. The term “sutured hemorrhoidopexy” we used in this manuscript is similar to RAR or suture mucopexy described in the literature. However, the term sutured hemorrhoidopexy reflects more precisely the surgical technique; a suture is used for lifting the hemorrhoidal complex to its origin.

Invasive treatment consisted of the stapled hemorrhoidopexy and traditional hemorrhoidectomy.

We asked two questions regarding complications. First, we asked the respondents “how often did you see a mild or severe complication after treatment for hemorrhoidal disease?” The respondents could choose between 1 and 5% or 5–10% or 10–20% or more than 20%. The second question was: “did you experience ‘no’ or ‘mild’ or ‘severe’ complications after use of either RBL, minimally invasive treatment, or invasive treatment?” This question allowed respondents to select more than one answer.

Results

Characteristics respondents

Background features of the respondents are shown in Table 1. A total of 100 participants returned a completed survey. The majority of hemorrhoidal disease was treated by the department of surgery (82.4%). Patients were mostly seen in outpatient clinics for the first time by a resident (44.2%) or consultant (37%).
Table 1

Background features of respondents

Background features

N

Percent

Characteristics of respondents

 Gender

  Male

  Female

76

24

76

24

 Function participants

  Consultant

84

84

  Fellow

  Resident

5

11

5

11

 Years of experience hemorrhoid treatment

  1–5 years

  5–10 years

  10–20 years

  > 20 years

11

26

39

24

11

26

39

24

 Type of hospital

  District

  University

  Private clinic

85

12

3

85

12

3

 Treatment by the department

  Surgery

  Gastroenterology

  Dermatology

82

9

9

82

9

9

 Contact first visit outpatient clinic

  Consultant

  Fellow

  Resident

  Nurse practitioner

38

12

44

6

38

12

44

6

Treatment for primary disease

Primary treatment of grade I disease

Respondents used RBL in 90% of the patients as the first treatment modality. Regarding minimally invasive treatment, respondents used laser therapy in < 1% and the sutured hemorrhoidopexy in 3% of the patients. Regarding invasive treatment, respondents used the stapled hemorrhoidopexy in 1% of the patients (Figs. 1 and 2).
Fig. 1

The use of rubber band ligation (RBL), minimal invasive treatment (laser therapy or sutured hemorrhoidopexy or Doppler-guided hemorrhoidal artery ligation (DG-HAL)), or invasive treatment (stapled hemorrhoidopexy or traditional hemorrhoidectomy) for grades I–IV hemorrhoidal disease according to the Goligher classification

Fig. 2

Flow diagram: initial treatment for grades I–IV hemorrhoids (RBL, rubber band ligation; minimal invasive treatment, laser therapy or sutured hemorrhoidopexy or DG-HAL; and invasive treatment, stapled hemorrhoidopexy and traditional hemorrhoidectomy)

Primary treatment of grade II disease

Fifty-nine percent of the respondents treated their patients with RBL. Regarding minimally invasive treatment, respondents used laser therapy in 4%, the sutured hemorrhoidopexy in 10%, and the DG-HAL in 10% of the patients. Regarding invasive treatment, respondents used the stapled hemorrhoidopexy in 2% and the traditional hemorrhoidectomy in 9% of the patients (Figs. 1 and 2).

Primary treatment of grade III disease

Six percent of the respondents used RBL for grade III hemorrhoidal disease. Regarding minimally invasive treatment, respondents used laser therapy in 4%, sutured hemorrhoidopexy in 24%, and the DG-HAL in 15% of the patients. Regarding invasive treatment, respondents used the stapled hemorrhoidopexy in 19% and traditional hemorrhoidectomy in 31% of the patients (Figs. 1 and 2).

Primary treatment of grade IV disease

Ninety percent of the respondents performed a (minimally) invasive treatment consisting of laser therapy in 2%, sutured hemorrhoidopexy in 21%, DG-HAL in 10%, stapled hemorrhoidopexy in 21%, and traditional hemorrhoidectomy in 37% of the patients (Figs. 1 and 2).

Treatment for recurrence after initial therapy

Recurrence after primary treatment of grade I disease

If complaints persisted in grade I hemorrhoidal disease, 65% of the respondents used conservative treatment. Twenty-eight percent of the respondents performed RBL. Regarding minimally invasive treatment, laser therapy is used < 1% and the sutured hemorrhoidopexy in 2% of the patients (Figs. 3 and 4).
Fig. 3

The use of conservative treatment, rubber band ligation (RBL), minimal invasive treatment (laser therapy or sutured hemorrhoidopexy or DG-HAL), or invasive treatment (stapled hemorrhoidopexy or traditional hemorrhoidectomy) in recurrent grades I–IV hemorrhoidal disease according to the Goligher classification

Fig. 4

Flow diagram: treatment in case of recurrent hemorrhoids for grades I–IV hemorrhoids (RBL, rubber band ligation; minimally invasive treatment: laser therapy, sutured hemorrhoidopexy, or DG-HAL; and invasive treatment, stapled hemorrhoidopexy and traditional hemorrhoidectomy)

Recurrence after primary treatment of grade II disease

Respondents chose for conservative treatment in 32% and for RBL in 46% of the patients. Regarding minimally invasive treatment, laser therapy was used in 1%, the sutured hemorrhoidopexy in 8%, and DG-HAL in 4% of the patients. Regarding invasive treatment, respondents used the stapled hemorrhoidopexy in 2% and the traditional hemorrhoidectomy in 4% of the patients (Figs. 3 and 4).

Recurrence after primary treatment of grade III disease

Respondents used conservative treatment in 14% and RBL in 27% of the patients. Regarding minimally invasive treatment, respondents used laser therapy in 2%, the sutured hemorrhoidopexy in 13%, and DG-HAL in 6% of the patients. Regarding invasive treatment, respondents used the stapled hemorrhoidopexy in 11% and traditional hemorrhoidectomy in 21% of the patients (Figs. 3 and 4).

Recurrence after primary treatment of grade IV disease

Recurrence in grade IV hemorrhoidal disease was treated conservatively by the respondents in 18% and RBL in 11% of the patients. Regarding minimally invasive treatment, respondents used laser therapy in 2%, the sutured hemorrhoidopexy in 14%, and DG-HAL in 5% of the patients. Regarding invasive treatment, respondents used the stapled hemorrhoidopexy in 14% and traditional hemorrhoidectomy in 28% of the patients (Figs. 3 and 4).

In case RBL failed, 80% of the respondents reported that a patient underwent a new RBL after a mean of 6.4 weeks. Sixty-four percent of the respondents performed two to three attempts of RBL before switching to another treatment option. In 41% of the cases, a RBL was performed by residents.

Complications

The majority of respondents (39%) reported a mild complication in 5–10% of the patients after any treatment for hemorrhoidal disease. In Fig. 5, the cumulative reported mild complications are shown for RBL, minimally invasive treatment, and invasive treatment.
Fig. 5

Cumulative reported mild complications (Clavien-Dindo 1–2) after RBL (rubber band ligation), minimal invasive treatment (laser therapy or sutured hemorrhoidopexy or DG-HAL), and invasive treatment (stapled hemorrhoidopexy and traditional hemorrhoidectomy)

Ninety-eight of the respondents reported major complications. Major complications occurred in less than 5% of the patients after any treatment for hemorrhoidal disease. In Fig. 6 the cumulative reported severe complications are shown for RBL, minimally invasive treatment, and invasive treatment.
Fig. 6

Cumulative reported severe complications (Clavien-Dindo 3–5) after RBL (rubber band ligation), minimal invasive treatment (laser therapy or sutured hemorrhoidopexy or DG-HAL) and invasive treatment (stapled hemorrhoidopexy or traditional hemorrhoidectomy)

Follow-up

Follow-up schedules were quite uniform. Eighty-five percent of the patients were seen 6 weeks after treatment [Fig. 7]. As the primary outcome of success, several definitions were used: 42.5% of the respondents used “patient satisfaction” and 36.7% “absence of complaints”.
Fig. 7

First and second outpatient visits after initial treatment for grades I–IV hemorrhoidal disease

Discussion

This Dutch survey showed areas of common practice for primary treatment of hemorrhoidal disease. However, it also demonstrated more varying practices regarding recurrent hemorrhoidal disease.

Grades I and II hemorrhoidal disease were mostly treated conservatively or with RBL according to the respondents. This is in accordance with several studies and guidelines describing the optimal treatment for low-grade hemorrhoidal disease [28, 29, 30]. A review, describing seven RCTs with a total number of 378 patients, confirmed better outcome in patients with grades I–II hemorrhoidal disease who used increased fiber intake [31]. In a recent RCT, comparing RBL with hemorrhoidal artery ligation (HAL) in 370 patients with grades II and III hemorrhoidal disease, they showed that HAL resulted in fewer recurrences. However, recurrence was similar to repeat RBL [32].

In grades III and IV hemorrhoidal disease, most respondents preferred (minimally) invasive treatment instead of RBL as the first treatment option. Recently, two RCTs compared the minimally invasive treatment options Doppler-guided hemorrhoidal artery ligation (DG-HAL) combined with a suture mucopexy versus a suture mucopexy alone. They showed low recurrence rates of 2–10% after 12–24 months follow-up for the suture mucopexy group [12, 13, 33]. However, long-term results of the suture mucopexy are limited: only one RCT fulfilled a follow-up of 2 years [13]. Despite the good results, the recurrence rate was high for grade IV hemorrhoidal disease (11–59%) [22, 34].

Respondents used the stapled hemorrhoidopexy or traditional hemorrhoidectomy more often in patients with grades III and IV hemorrhoidal disease than in patients with grades II and III hemorrhoidal disease. A meta-analysis of almost 1000 patients demonstrated a higher long-term recurrence rate of 42% in patients undergoing a stapled hemorrhoidopexy compared to the traditional hemorrhoidectomy (25%) [26, 35]. Recently, Watson et al. conducted a multicenter RCT, comparing stapled hemorrhoidopexy to traditional excisional surgery in 777 patients with grade III hemorrhoidal disease. The overall quality of life was significantly better after traditional hemorrhoidectomy with a follow-up of 24 months. They concluded that the traditional hemorrhoidectomy is superior for the primary management of grades II–IV hemorrhoidal disease compared to the stapled hemorrhoidopexy [26].

In case of recurrent grades I and II hemorrhoidal disease, most respondents used conservative treatment or performed RBL. For recurrent grades III and IV hemorrhoidal disease, respondents used more often invasive treatments. As there are to our knowledge no studies focusing on what to do in case of recurrent hemorrhoidal disease, there remains a debate what the next step should be in these patients.

Ideally, an international guideline will be conducted for primary and recurrent treatment of hemorrhoidal disease. A barrier for such treatment algorithm is the lack of a known uniformly accepted core outcome set (COS). Comparing data and pooling results of clinical trials used in evidence-based health care, can only be conducted if outcomes are comparable. Therefore, we started the development of a COS assessing the treatment for hemorrhoidal disease in clinical trials [36].

Some limitations of this study should be noted. Firstly, the grading of hemorrhoids can be surgeon dependent. This may result in a wide variation in classification of the severity of hemorrhoids. Secondly, the frequency of grade IV hemorrhoids is less common than the grades I, II, and III hemorrhoids. Some respondents may not have clinical experience in the treatment of grade IV hemorrhoids. Thirdly, due to the lack of a central database comprising detailed information of Dutch surgeons, the survey was sent to all Dutch colorectal consultants, fellows, and surgical residents of the Dutch Association for Surgery. They were requested to reply only in case the respondent was treated for hemorrhoidal disease regularly. This approach lacks insight in the exact response of the target population. Fourthly, due to the nature of surveys: respondents represent an intrinsic selection bias and answer options may be interpreted differently by different responders. Fifthly, the study surveyed only Dutch colorectal consultants and residents; therefore, the results cannot be generalized to surgeons worldwide. In most countries, daily care for patients with hemorrhoidal disease is conducted by surgeons. Therefore, in our survey we only assessed the surgical point of view regarding hemorrhoidal disease treatment. But we are aware that in some countries other healthcare professionals like gastroenterologists and dermatologists are involved in daily care for these patients.

Conclusion

This survey showed that there remains considerable variation in the treatment of hemorrhoidal disease, especially in case of recurrence, in the Netherlands. This implies a need for an evidence-based (international) guideline regarding the treatment of hemorrhoidal disease.

Author contribution

Robin R. van Tol, M.D.: analysis and interpretation of data, drafting of the article, final approval of article

Marieke P.A. Bruijnen, M.D.: acquisition, analysis and interpretation of data, drafting of the article, final approval of article

Jarno Melenhorst, M.D., Ph.D.: acquisition, analysis and interpretation of data, drafting of the article, final approval of article

Sander M.J. van Kuijk, Ph.D.: analysis and interpretation of data, drafting of the article, final approval of article

Laurents P. Stassen, M.D., Ph.D., Prof.: conception and design, interpretation of data, revision and final approval of article

Stéphanie O. Breukink M.D., Ph.D.: conception and design, interpretation of data, revision and final approval of article

Notes

Compliance with ethical standards

Ethics approval

The ethical committee of Maastricht University Medical Centre confirmed that the Medical Research Involving Human Subjects Act (WMO) does not apply to the abovementioned study and that an official approval of this study by the committee is not required.

References

  1. 1.
    Russell, MMG, Ko CY (2012) Management of hemorrhoids: mainstay of treatment remains diet modification and office-based procedures July 16, 2012Google Scholar
  2. 2.
    Loder PB, Kamm MA, Nicholls RJ, Phillips RKS (1994) Haemorrhoids: pathology, pathophysiology and aetiology. Br J Surg 81(7):946–954CrossRefPubMedGoogle Scholar
  3. 3.
    Riss S, Weiser FA, Schwameis K, Riss T, Mittlböck M, Steiner G, Stift A (2012) The prevalence of hemorrhoids in adults. Int J Color Dis 27(2):215–220CrossRefGoogle Scholar
  4. 4.
    Elbetti C, Giani I, Novelli E, Fucini C, Martellucci J (2015) The single pile classification: a new tool for the classification of haemorrhoidal disease and the comparison of treatment results. Updat Surg 67(4):421–426CrossRefGoogle Scholar
  5. 5.
    Alonso-Coello P et al (2005) Laxatives for the treatment of hemorrhoids. Cochrane Database Syst Rev 4:CD004649Google Scholar
  6. 6.
    Alonso-Coello P, Zhou Q, Martinez-Zapata MJ, Mills E, Heels-Ansdell D, Johanson JF, Guyatt G (2006) Meta-analysis of flavonoids for the treatment of haemorrhoids. Br J Surg 93(8):909–920CrossRefPubMedGoogle Scholar
  7. 7.
    Perera N et al (2012) Phlebotonics for haemorrhoids. Cochrane Database Syst Rev 8:CD004322Google Scholar
  8. 8.
    MacRae HM, McLeod RS (1997) Comparison of hemorrhoidal treatments: a meta-analysis. Can J Surg 40(1):14–17PubMedPubMedCentralGoogle Scholar
  9. 9.
    Hoyuela C, Carvajal F, Juvany M, Troyano D, Trias M, Martrat A, Ardid J, Obiols J (2016) HAL-RAR (Doppler guided haemorrhoid artery ligation with recto-anal repair) is a safe and effective procedure for haemorrhoids. Results of a prospective study after two-years follow-up. Int J Surg 28:39–44CrossRefPubMedGoogle Scholar
  10. 10.
    Faucheron JL, Trilling B, Reche F (2015) HAL-RAR(R) procedure: a safe operation for hemorrhoids. J Visc Surg 152(2):143–144CrossRefPubMedGoogle Scholar
  11. 11.
    Faucheron JL, Poncet G, Voirin D, Badic B, Gangner Y (2011) Doppler-guided hemorrhoidal artery ligation and rectoanal repair (HAL-RAR) for the treatment of grade IV hemorrhoids: long-term results in 100 consecutive patients. Dis Colon Rectum 54(2):226–231CrossRefPubMedGoogle Scholar
  12. 12.
    Aigner F, Kronberger I, Oberwalder M, Loizides A, Ulmer H, Gruber L, Pratschke J, Peer S, Gruber H (2016) Doppler-guided haemorrhoidal artery ligation with suture mucopexy compared with suture mucopexy alone for the treatment of grade III haemorrhoids: a prospective randomized controlled trial. Color Dis 18(7):710–716CrossRefGoogle Scholar
  13. 13.
    Zhai M et al (2016) A randomized controlled trial comparing suture-fixation mucopexy and Doppler-guided hemorrhoidal artery ligation in patients with grade III hemorrhoids. Gastroenterol Res Pract 2016:8143703CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Shanmugam V, Muthukumarasamy G, Cook JA, Vale L, Watson AJ, Loudon MA (2010) Randomized controlled trial comparing rubber band ligation with stapled haemorrhoidopexy for grade II circumferential haemorrhoids: long-term results. Color Dis 12(6):579–586CrossRefGoogle Scholar
  15. 15.
    Longo A (2002) Stapled anopexy and stapled hemorrhoidectomy: two opposite concepts and procedures. Dis Colon Rectum 45(4):571–572 author reply 572CrossRefPubMedGoogle Scholar
  16. 16.
    Burch J et al (2008) Stapled haemorrhoidectomy (haemorrhoidopexy) for the treatment of haemorrhoids: a systematic review and economic evaluation. Health Technol Assess 12(8): p. iii-iv, ix-x, 1–193Google Scholar
  17. 17.
    Majeed S et al (2015) Comparison of open and closed techniques of haemorrhoidectomy in terms of post-operative complications. J Ayub Med Coll Abbottabad 27(4):791–793PubMedGoogle Scholar
  18. 18.
    Arroyo A, Pérez F, Miranda E, Serrano P, Candela F, Lacueva J, Hernández H, Calpena R (2004) Open versus closed day-case haemorrhoidectomy: is there any difference? results of a prospective randomised study. Int J Colorectal Dis 19(4):370–373CrossRefPubMedGoogle Scholar
  19. 19.
    Bouchard D, Abramowitz L, Castinel A, Suduca JM, Staumont G, Soudan D, Devulder F, Pigot F, Varastet M, Ganansia R, Groupe de Recherche En Proctologie de la Société Nationale Française de Colo-Proctologie (GREP), Club de Réflexion des cabinets et Groupe d'Hépato-Gastroentérologie (CREGG) (2013) One-year outcome of haemorrhoidectomy: a prospective multicentre French study. Color Dis 15(6):719–726CrossRefGoogle Scholar
  20. 20.
    Shanmugam V, Thaha MA, Rabindranath KS, Campbell KL, Steele RJC, Loudon MA (2005) Systematic review of randomized trials comparing rubber band ligation with excisional haemorrhoidectomy. Br J Surg 92(12):1481–1487CrossRefPubMedGoogle Scholar
  21. 21.
    Pucher PH, Sodergren MH, Lord AC, Darzi A, Ziprin P (2013) Clinical outcome following Doppler-guided haemorrhoidal artery ligation: a systematic review. Color Dis 15(6):e284–e294CrossRefGoogle Scholar
  22. 22.
    Giordano P, Overton J, Madeddu F, Zaman S, Gravante G (2009) Transanal hemorrhoidal dearterialization: a systematic review. Dis Colon Rectum 52(9):1665–1671CrossRefPubMedGoogle Scholar
  23. 23.
    Rivadeneira DE, Steele SR, Ternent C, Chalasani S, Buie WD, Rafferty JL, Standards Practice Task Force of The American Society of Colon and Rectal Surgeons (2011) Practice parameters for the management of hemorrhoids (revised 2010). Dis Colon Rectum 54(9):1059–1064CrossRefPubMedGoogle Scholar
  24. 24.
    Cataldo P, Ellis CN, Gregorcyk S, Hyman N, Buie WD, Church J, Cohen J, Fleshner P, Kilkenny J 3rd, Ko C, Levien D, Nelson R, Newstead G, Orsay C, Perry WB, Rakinic J, Shellito P, Strong S, Ternent C, Tjandra J, Whiteford M, Standards Practice Task Force, The American Society of Colon and Rectal Surgeons, USA (2005) Practice parameters for the management of hemorrhoids (revised). Dis Colon Rectum 48(2):189–194CrossRefPubMedGoogle Scholar
  25. 25.
    Brown S, Tiernan J, Biggs K, Hind D, Shephard N, Bradburn M, Wailoo A, Alshreef A, Swaby L, Watson A, Radley S, Jones O, Skaife P, Agarwal A, Giordano P, Lamah M, Cartmell M, Davies J, Faiz O, Nugent K, Clarke A, MacDonald A, Conaghan P, Ziprin P, Makhija R (2016) The HubBLe trial: haemorrhoidal artery ligation (HAL) versus rubber band ligation (RBL) for symptomatic second- and third-degree haemorrhoids: a multicentre randomised controlled trial and health-economic evaluation. Health Technol Assess 20(88):1–150CrossRefGoogle Scholar
  26. 26.
    Watson AJ, Hudson J, Wood J, Kilonzo M, Brown SR, McDonald A, Norrie J, Bruhn H, Cook JA, eTHoS study group (2016) Comparison of stapled haemorrhoidopexy with traditional excisional surgery for haemorrhoidal disease (eTHoS): a pragmatic, multicentre, randomised controlled trial. Lancet 388(10058):2375–2385CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Shaw HM, Milton GW, Farago G, McCarthy WH (1978) Endocrine influences on survival from malignant melanoma. Cancer 42(2):669–677CrossRefPubMedGoogle Scholar
  28. 28.
    Rivadeneira DE, Steele SR, Ternent C, Chalasani S, Buie WD, Rafferty JL (2011) Practice parameters for the management of hemorrhoids (revised 2010). Dis Colon Rectum 45:1059–1064CrossRefGoogle Scholar
  29. 29.
    Cataldo P, Ellis CN, Gregorcyk S, Hyman N, Buie WD, Church J et al (2005) Practice parameters for the management of hemorrhoids (revised). Dis Colon Rectum 48:189–194CrossRefPubMedGoogle Scholar
  30. 30.
    dr. M.S. Dunker, d.D.D.E.Z., dr. N.A.T. Wijffels, dr. M.J. Lahaye, dr. O. van Ruler, dr. E. Mitalas, dr. R.J.F. Felt-Bersma, drs. M.T. Bousema, dr (2015) P.G. Doornebosch, Richtlijn ProctologieGoogle Scholar
  31. 31.
    Alonso-Coello P, Mills E, Heels-Ansdell D, Lopez-Yarto M, Zhou Q, Johanson JF, Guyatt G (2006) Fiber for the treatment of hemorrhoids complications: a systematic review and meta-analysis. Am J Gastroenterol 101(1):181–188CrossRefPubMedGoogle Scholar
  32. 32.
    Brown SR, Tiernan JP, Watson AJM, Biggs K, Shephard N, Wailoo AJ, Bradburn M, Alshreef A, Hind D, HubBLe Study team (2016) Haemorrhoidal artery ligation versus rubber band ligation for the management of symptomatic second-degree and third-degree haemorrhoids (HubBLe): a multicentre, open-label, randomised controlled trial. Lancet 388(10042):356–364CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Schuurman JP, Borel Rinkes IH, Go PM (2012) Hemorrhoidal artery ligation procedure with or without Doppler transducer in grade II and III hemorrhoidal disease: a blinded randomized clinical trial. Ann Surg 255(5):840–845CrossRefPubMedGoogle Scholar
  34. 34.
    Infantino A (2010) Transanal haemorrhoidal artery echodoppler ligation and anopexy (THD) is effective for II and III degree haemorrhoids. A prospective multicentre study. Color Dis 12(12):1274CrossRefGoogle Scholar
  35. 35.
    Nisar PJ, Acheson AG, Neal KR, Scholefield JH (2004) Stapled hemorrhoidopexy compared with conventional hemorrhoidectomy: systematic review of randomized, controlled trials. Dis Colon Rectum 47(11):1837–1845CrossRefPubMedGoogle Scholar
  36. 36.
    van Tol RR et al (2017) Protocol for the development of a core outcome set (COS) for hemorrhoidal disease: an international Delphi study. Int J Color Dis 32(7):1091–1094CrossRefGoogle Scholar

Copyright information

© The Author(s) 2018

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Authors and Affiliations

  1. 1.Department of Surgery and Colorectal Surgery, Academic Hospital MaastrichtMaastricht University Medical CenterMaastrichtThe Netherlands
  2. 2.Department of Clinical Epidemiology and Medical Technology AssessmentMaastricht University Medical CentreMaastrichtthe Netherlands

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