Keywords
hemorrhoids - hemorrhoidectomy - transanal hemorrhoroidal dearterialization - local
anesthesia - ligation anopexy - ambulatory surgery
Palavras-chave
hemorroidas - hemorrhoidectomia - dearterialização hemorroidária transanal - anestesia
local - anopexia - cirurgia ambulatória
Introduction
Hemorrhoidal disease (HD) is one of the most common benign human disorders with an
incidence of 4% of the global population in the western world, with high impact on
the quality of life, health systems, and social costs.[1] Since the dawn of time, there have been many attempts to find a highly effective,
minimally painful technique for the management of symptomatic HD.[2] Surgical treatment is still guided by the grade of hemorrhoidal prolapse.[3] Open hemorrhoidectomy (OH) is considered the gold-standard treatment for symptomatic
grades III and IV HD; however, it is associated with severe postoperative pain and
other complications, such as urinary retention, bleeding, infection, anal stenosis,
and impairment of defecation.[4]
[5]
[6] Although various devices such as ultrasonic/radiofrequency scalpels have been adopted
to reduce posthemorrhoidectomy complications, no significant differences in postoperative
complications and long-term outcomes have been reported.[1] Stapled hemorrhoidopexy (SH), which was created for treating circumferential prolapsing
HD, is widely used across the world, but it does not seem to offer any significant
advantages over OH.[7]
[8] Non-excisional HD surgery has become more frequent during the past decade.[4]
[9] Doppler-guided hemorrhoidal artery ligation (DGHAL), also known as transanal hemorrhoidal
dearterialization (THD),[10] has been demonstrated to achieve good outcomes for grades II and III HD with less
postoperative pain and shorter sick leave, but increased risk of recurrence if compared
with OH or SH.[9]
[11]
[12] The UK National Institute for Health and Care Excellence (NICE) has affirmed that
hemorrhoidal artery ligation is ‘an efficacious alternative to conventional hemorrhoidectomy
or stapled hemorrhoidopexy’, without ‘major safety concerns’[13]. With the help of a transanal Doppler device, terminal branches of the superior
hemorrhoidal artery are detected and ligated, thus reducing the arterial inflow and
causing shrinkage of hemorrhoid cushions without the need of hemorrhoid removal. Plication
of hemorrhoidal prolapse is often combined to control the prolapse. Doppler guidance
can help to identify the arteries, but it is not necessary for a good outcome.[14]
[15] A simpler and cheaper technique is ligation anopexy (LA).[16]
[17] This technique is identical to DGHAL but without the use of Doppler. Since hemorrhoidal
vessels have a constant anatomical location penetrating the hemorrhoid at its base,
systematically positioning ligations all around the anal canal consents to diminish
the blood flow to the hemorrhoidal plexus, and to shrink the prolapsed hemorrhoids.
Ligation anopexy has been proposed for grades II–III HD, with encouraging results
compared with DGHAL: shorter operative time, feasibility under local anesthesia and
as office-based, low postoperative pain, comparable short-term outcomes, lower costs,
and favorable long-term outcomes.[15]
[18]
[19]
Hemorrhoidal disease surgery is generally performed as an inpatient procedure under
general or loco regional anesthesia. However, some studies have demonstrated the feasibility
and safety of performing surgery for HD in a day-case basis under local anesthesia
with considerable savings in health care costs.[20]
[21]
[22] Still, the office-based approach for HD surgery is very rare and limited to few
centers.
The aim of the present study was to determine the impact on postoperative outcome
and cost-effectiveness of performing LA and OH in an ambulatory setting in an Italian
academic center.
Patients and Methods
This retrospective observational study was designed to evaluate the impact on postoperative
outcome and cost-effectiveness of performing hemorrhoids surgery in an ambulatory
setting in comparison with the conventional approach with hospitalization.
The study was conducted at the Second Surgical Unit of the Azienda Ospedaliero-Universitaria
Arcispedale S. Anna of Ferrara, located in the Northeast of Italy. Once the regional
ethics committee's approval was obtained, data from all consecutive patients scheduled
for surgery for grades II and III HD were collected over a period of 4 years (January
2015–December 2018).
The inclusion criteria were symptomatic grades II and III HD, American Society of
Anesthesia (ASA) score 1 to 3, age over 18, good physical and mental health. The exclusion
criteria included inflammatory bowel disease (IBD), fecal incontinence, pregnancy,
previous surgery for cancer (last 12 months), severe allergy, acute thrombosed hemorrhoids,
anal stricture, anal fissure, anal fistula, or medical conditions that made patients
unfit for elective surgery.
Those who accepted to enter the trial were assigned to treatment by ambulatory surgery
(group A) or surgery in a hospital setting (group H). In either group, patients underwent
OH or AL according to the usual clinical practice for patient care and considering
the symptoms, the grade of the hemorrhoids, but also the preference of the patient,
with no randomization. The same surgical team performed all surgeries.
Patient data were collected over 24 months at least. Patients were reviewed postoperatively
on days 7, 15, 30, and at 6, 12, and 24 months.
The primary outcome was time required to return to work/daily activities. Secondary
outcomes included postoperative pain and complications, cost-effectiveness, and patient
satisfaction. Hemorrhoidal disease recurrence at 12 and 24 months was registered.
All operations were performed in the supine lithotomy position. All patients were
given a Fleet enema prior to surgery and intravenous antibiotic prophylaxis (metronidazole).
In group A, all the procedures were performed under local anesthesia with ropivacaine
(10 mL) intra-sphincteric injection, without sedation. In group H, the procedures
were performed under general or loco-regional anesthesia.
Ligation anopexy was performed under direct vision using an Eisenhammer rectal speculum,
without the use of Doppler transducer. We placed absorbable sutures to interrupt hemorrhoidal
artery blood flow 2 cm above the dentate line, affixing the mucosa and submucosa to
the underlying internal sphincter and pulling the redundant mucosa distally in a vertical
mucopexy at the same points.[17] This procedure was performed for each pile. The procedure was tailored to each patient,
and an average of 4 to 6 sutures at 1, 3, 5, 7, 8, and 11 of the anal clock were used
during surgery.[18]
The Milligan-Morgan open hemorrhoidectomy (OH) was conducted with diathermy or ultrasonic/radiofrequency
scalpel.[3] The number and location of the removed piles was tailored to each patient.
The patients were discharged ∼ 60 minutes after surgery in the ambulatory setting,
after meeting standard ambulatory surgery discharge criteria. At discharge, adequate
painkillers and laxatives were prescribed, and an emergency telephone number was given
to the patient for use in case of need. The length of hospital stay (measured by hours)
was recorded. The pain levels were registered using the visual analog scale (VAS),
for every day during the 1st postoperative week, then at 2, 3, and 4 weeks. Adverse events (AEs) or complications
were analyzed according to the Clavien Dindo Grading System applied to hemorrhoids
surgery[23] at day 30 after surgery, comparing them for procedure (LA versus. OH) and setting
(A versus. H). The amount of time taken to return to work/daily activities (days)
was registered. To determine the costs-effectiveness of ambulatory surgery versus
hospitalization, we collected both direct and indirect costs (i.e., operating room,
drugs, exams, visits, length of hospital stay, human resources, cost of complications,
reoperations, and readmissions within 30 days after operation). Total costs were calculated
per patient.
To evaluate patient satisfaction, the Patient Satisfaction Consultation Questionnaire
(PSCQ-7)[24] and Core Questionnaire Patient Satisfaction (COPS)[25] were administered to all patients on the30-day follow-up visit. Hemorrhoidal disease
recurrence at 12 and 24 months after operation was recorded. To assess recurrence,
we used the dichotomous definition proposed by Shanmugam et al.,[26] meaning a healed or improved (identified with 1) patient who, at the end of the
study period (after 12 and 24 months), did not present HD symptoms. In case of presence
of symptoms, with the need for further treatment, patients were considered recurrent
(identified with 2).
Statistical Analysis
The sample size calculation was guided by estimates of quicker return to daily activities
or to work, following ambulatory surgery and mini-invasive surgery for HD. In a previous
study, patients who underwent DGHAL had a quicker return to work compared with those
who underwent SH, with an effect size of 0.045.[11] Given a matched allocation 1:1 between treatments (ambulatory patients) and control
arms (hospitalized patients), and a two-sided 95.0% confidence interval for a single
proportion extended to 10% on either side, with an assumed dropout rate of 5% at 6
months, to complete the study, a sample size of 250 subjects (125 treatment arm and
125 control group) was required.
The Shapiro-Wilk test was used to test for normality of distribution of the continuous
variables. In the presence of symmetry of the distributions, the variables were represented
with mean and standard deviation (SD) or, in the case of non-normal distribution,
with the median value and interquartile range (1Q–3Q); the categorical data were expressed
as total numbers and percentages. Statistical comparisons in the two groups were assessed
using the Pearson's χ2 test or Fisher exact test or Chi-squared test depending on
the minimal expected count in each crosstab, using the two-way analysis of variance
(ANOVA); for continuous covariates, the Student t test for normally distributed variables or the Mann-Whitney test for asymmetric variables
were used. All analyses were performed using Stata 15.1 SE (Stata Corporation, College
Station, TX, USA). All tests were two-sided and a p-value of < 0.05 was considered statistically significant.
This report complies with the strengthening the reporting of cohort studies in surgery
(STROCSS) criteria.[27]
Results
Out of 247 patients, 3 were excluded (two for allergy and one for fecal incontinence)
and 244 were allocated as follows: 122 patients underwent ambulatory treatment of
hemorrhoids (group A) and 122 underwent hemorrhoid surgery in a hospital setting (group
H). Four patients were lost at follow-up, so 240 patients were studied for cost-effectiveness
and safety ([Fig. 1]). At baseline, groups A and H were completely well matched ([Table 1]). No significant difference was found in age, gender, body mass index (Kg/m2), ASA
score, rate of work activity, and rate of previous HD surgery. No significant statistical
differences were observed in the distribution of HD grade and number of piles, or
in the distribution of the two procedures (LA and OH) between the two groups. The
mean length of follow-up was 26.3 ± 11.3 months in group A and 29.6 ± 14.4 months
in group H. The duration of operations regardless the procedure, was significantly
shorter in group A, p < 0.001 ([Table 2]). No intra-operative complications occurred. All ambulatory patients were discharged
after the procedure. The median length of hospital stay in group A was of 1 hour,
compared with 10 hours in group H (p < 0.001) ([Table 2]). In group H, the median hospital stay was longer for patients undergoing OH (27 hours)
compared with patients undergoing LA (10 hours); p < 0.001.
Table 1
Patient characteristics at baseline
|
Variable
|
Group A
Ambulatory
|
Group H
Hospitalized
|
P-value
|
|
Age (mean ± SD)
|
54.07 ± 12.07
|
53.16 ± 11.8
|
NS
|
|
Females (N. %)
|
74 (61.7)
|
61 (50.8)
|
NS
|
|
Males (N, %)
|
46 (38.3)
|
59 (49.2)
|
NS
|
|
Body Mass Index (Kg/m2) (N, %)
|
|
|
NS
|
|
< 25
|
100 (83.3)
|
97 (80.8)
|
|
|
25–29.9
|
17 (14.2)
|
20 (16.7)
|
|
|
> 30
|
3 (2.5)
|
3 (2.5)
|
|
|
American Society of Anesthesia
score (N. %)
|
|
|
NS
|
|
ASA I
|
73 (60.8)
|
71 (59.2)
|
|
|
ASA II
|
39 (32.5)
|
39 (32.5)
|
|
|
ASA III
|
38 (6.7)
|
10 (8.3)
|
|
|
Work activity (N, %)
|
103 (85.8)
|
102 (85)
|
NS
|
|
Previous surgery
for hemorrhoids (N, %)
|
6 (5)
|
12 (10)
|
NS
|
|
Grade 2 hemorrhoids (N, %)
|
54 (45)
|
50 (41.7)
|
NS
|
|
Grade 3 hemorrhoids (N, %)
|
66 (55)
|
70 (58.3)
|
NS
|
|
Number of piles
|
|
|
NS
|
|
1
|
9
|
5
|
|
|
2
|
30
|
36
|
|
|
3
|
63
|
63
|
|
|
4
|
10
|
7
|
|
|
5
|
8
|
9
|
|
|
LA (N, %)
|
62 (54.4)
|
52 (45.6)
|
NS
|
|
OH (N, %)
|
58 (46)
|
68 (54)
|
NS
|
|
Length of follow-up (months) (mean ± SD)
|
26.3 ± 11.3
|
29.6 ± 14.4
|
NS
|
Abbreviations: LA, ligation anopexy; N, number; OH, open hemorrhoidectomy; SD, standard
deviation; NS, not significant.
Table 2
Early and late postoperative outcomes
|
Ambulatory
|
Hospitalized
|
P-value
|
|
Group A
120
|
LA
62
|
OH
58
|
Group H
120
|
LA
52
|
OH
68
|
|
|
Length of procedure (min)
Mean ± SD
|
27.5 ± 9.3
|
22.2 ± 6.6
|
33.7 ± 7.9
|
32.4 ± 8.4
|
28.9 ± 8.4
|
35.07 ± 7.5
|
< 0.001
|
|
Hospital length of stay (hours)
Median (range)
|
1 (1–2)
|
1 (1–2)
|
1 (1–3)
|
10 (8–120)
|
10 (8–28)
|
27 (9–120)
|
< 0.001
|
|
Return to work/daily activities (days)
Mean ± SD
|
8.4 ± 4.8
|
8.5 ± 4.7
|
8.4 ± 4.9
|
12.5 ± 3
|
12.05 ± 2.9
|
12.9 ± 3.04
|
< 0.001
|
|
HD recurrence at 12 months (N, %)
|
5 (4.2)
|
4 (6.4)
|
1 (1.7)
|
4 (3.3)
|
4 (7.7)
|
−
|
< 0.01
|
|
Reoperation after 12 months (N, %)
|
3 (2.5)
|
3 (4.8)
|
−
|
2 (1.6)
|
2 (3.8)
|
−
|
NS
|
|
HD recurrence at 24 months (N, %)
|
3 (2.5)
|
3 (4.8)
|
−
|
2 (1.6)
|
2 (3.8)
|
−
|
NS
|
Abbreviations: HD, hemorrhoidal disease; LA, ligation anopexy; N, number; OH, open
hemorrhoidectomy; SD, standard deviation; NS, not significant.
Fig. 1 Study design.
The median VAS pain score at 1 week, 2 and 3 weeks, and 1 month after surgery was
lower and reported only in the 1st postoperative week in group A than in group H, in which the median VAS was higher
and registered until 4 weeks after surgery; p < 0.01 ([Fig. 2]). Focusing on the procedures, patients undergoing LA reported significantly lower
VAS score in comparison with patients undergoing OH (p < 0.01). The mean number of days to return to work/daily activities was 8.4 ± 4.8
days in group A, compared with 12.5 ± 3 days in group H (p < 0.001), regardless of the different procedures ([Table 2]).
Fig. 2 Postoperative pain in group A and group H.
We observed more postoperative complications in hospitalized patients (12.5%) than
in ambulatory patients (7.5%), p < 0.001; postoperative urinary retention was more frequent in group H (5.8%) than
in group A (0.8%), p < 0.01, likely due to spinal anesthesia ([Table 3]). We did not observe any early post-operative hemorrhage. Overall morbidity (only
grade I and II according to Clavien-Dindo classification) was 12.3% after LA procedure
and 7.9% after OH procedure (p < 0.01), regardless of the operation setting. Few grade-one anal complications were
observed without any significant statistical difference between groups A and H. However,
hemorrhoids thrombosis occurred only after LA in both settings (4.8% in group A, and
5,7% in group H), p < 0.01. Urgency or mild fecal incontinence occurred in two patients operated on OH.
One patient of H group required prolonged hospital stay for severe pain occurred after
OH ([Table 3]). None of the patients required readmission, blood transfusion or reoperation within
30 days after surgery. No grade III, IV, and V complications were described in both
groups.
Table 3
Postoperative complications (within 30 days after surgery)
|
Ambulatory
|
Hospitalized
|
P-value
|
|
Group A
120
|
LA
62
|
OH
58
|
Group H
120
|
LA
52
|
OH
68
|
|
|
Overall postoperative complications
(Clavien-Dindo)
(N, %)
|
9 (7.5)
|
5 (8.1)
|
4 (6.9)
|
15 (12.5)
|
9 (17.3)
|
6 (8.8)
|
< 0.001
|
|
Grade I
|
9 (7.5)
|
5 (8.1)
|
4(6.8)
|
14 (11.7)
|
9 (17.3)
|
5 (7.3)
|
< 0.01
|
|
Grade I
urinary retention
|
1 (0.8)
|
−
|
1 (1.7)
|
7 (5.8)
|
4 (7.7)
|
3 (4.4)
|
< 0.01
|
|
Grade I
|
8(6.6)
|
5(8.1)
|
3 (5.1)
|
7 (5.8)
|
5 (9.6)
|
2 (2.9)
|
NS
|
|
Anal complications
|
|
|
|
|
|
|
|
|
Bleeding
|
−
|
−
|
−
|
−
|
−
|
−
|
|
|
Thrombosed hemorrhoids
|
3 (2.5)
|
3 (4.8)
|
−
|
3 (2.5)
|
3 (5.7)
|
−
|
< 0.01
|
|
Prolapse
|
−
|
−
|
−
|
−
|
−
|
−
|
NS
|
|
Fissure
|
2 (1.6)
|
1 (1.6)
|
1 (1.5)
|
2 (1.6)
|
1 (1.9)
|
1 (1.5)
|
NS
|
|
Stenosis
|
−
|
−
|
−
|
−
|
−
|
−
|
NS
|
|
Impaction
|
1 (0.8)
|
−
|
1 (1.5)
|
−
|
−
|
−
|
NS
|
|
Local infection
|
1 (0.8)
|
1 (1.6)
|
−
|
1 (0.8)
|
1 (1.9)
|
−
|
NS
|
|
Urgency or mild incontinence
|
1 (0.8)
|
−
|
1 (1.5)
|
1 (0.8)
|
−
|
1 (1.5)
|
NS
|
|
Grade II
persistent pain with prolonged hospital stay
|
0
|
−
|
−
|
1 (0.8)
|
−
|
1 (1.5)
|
NS
|
Abbreviations: LA, ligation anopexy; OH, open hemorrhoidectomy; NS, not significant.
Complications according to the Clavien-Dindo grading system in relation with the setting
and the type of procedure.
There was no significant difference between group A (4.2%) and group H (3.3%) concerning
recurrence at 12 months ([Table 2]). However, comparing the surgical procedures, recurrence was significantly higher
for LA (6.4% in group A and 7.7% in group H) than OH (1.7% and 0% respectively) (p < 0.01); in particular, persistent hypertrophic external skin tags and recurrent
hemorrhoidal prolapse were the most common long-term complications observed after
LA.
The rate of reoperation, which consisted of OH procedure in each recurrent patient,
was 2.5% in Group A and 1.6% in group H (p: NS). HD recurrence after 24 months was
stable: 2.5% in group A and 1.6% in group H, occurring in both groups after LA procedure
([Table 2]).
Cost analysis evidenced that the total mean institutional costs per patient were significantly
lower in ambulatory setting (351.3 euros) compared with hospitalized regimen (1,746
euros); p < 0.001([Table 4]).
Table 4
Comparison of institutional costs per patient between groups A and H (mean and standard
deviation)
|
Variable
|
Ambulatory
|
Hospitalized
|
P-value
|
|
Operating room (pharmacy, equipment, staff, operating theater) (Euro)
|
275 ± 0
|
408 ± 182.0
|
< 0.001
|
|
Surgical ward (hospital stay, pharmacy, laboratory) (Euro)
|
0
|
1237.5 ± 262.7
|
< 0.001
|
|
Outpatient clinic visits (Euro)
|
76.33 ± 23.02
|
116 ± 32.14
|
< 0.001
|
|
Total mean institutional costs per patient (Euro)
|
351.3 ± 23
|
1746.4 ± 347.01
|
< 0.001
|
Patient satisfaction according to the COPS and PSCQ-7 questionnaire was high in both
groups: the 97% of patients operated in an ambulatory setting reported that they would
repeat the procedure under local anesthesia and with early discharge after the procedure.
Discussion
Hemorrhoidal disease can be managed appropriately and successfully in an outpatient
setting, with early discharge, better pain control, lower postoperative complications,
considerable savings in health care costs, and high patient satisfaction. We observed
that both LA and OH could be performed in an outpatient setting with a superiority
of LA over OH for shorter operative times and lower postoperative pain scores ([Fig. 2]), as confirmed by the current literature.[16]
[17]
[28]
[29] The lower pain scores associated with LA might be explained by the placement of
sutures in the non-sensitive anal mucosa above the dentate line,[30] as well as the absence of surgical wounds. The registration of higher VAS score
after OH was explained by the thermal effect of diathermy, the presence of wounds
in the sensitive anal mucosa, and anal spasm. On the other hand, the sutures performed
during LA may cause a venous stasis, thus increasing the risk of thrombosis. In fact,
our results confirmed that thrombosis of the hemorrhoidal veins occurred only after
LA in both settings ([Table 3]).
Concerning postoperative complications, hospitalized patients seemed to have more
postoperative complications (12.5%), compared with ambulatory patients (7.5%), due
to the higher rate of urinary retention (5.7%) after spinal anesthesia; however, focusing
the attention on the procedure, we observed that overall morbidity was 12.3% after
LA and 7.9% after OH, regardless of the setting. In fact, even if LA is considered
a less invasive technique, it is not without complications: in a larger Italian series
in which all patients underwent DGHAL under general or spinal anesthesia, significant
postoperative pain and urinary retention were reported by 13% and 8.6% of the patients,
with an overall morbidity of 18%.[31] When DGHAL was compared with SH and OH in two randomized control trials (RCTs),
respectively,[11]
[32] patients undergoing DGHAL had less postoperative pain and a faster return to work,
without producing a significantly higher risk in terms of AEs. A recent open-label
RCT comparing THD with minimal OH reported that minimal OH had an immediate postoperative
course, similar to DGHAL.[33]
Regarding the resumption time of work and daily activities, used as primary index
of clinical outcome, we observed that the mean time of return to work/daily activities
was 8.4 days in group A compared with 12.5 days in group H, regardless of the different
operations ([Table 2]). This result might be explained by cultural and socioeconomic reasons: patients
who preferred the ambulatory setting with simpler preoperative preparation, easier
hospital access and much shorter hospital stay might be better disposed to a faster
recovery and an earlier return to normal daily activities. However, this analysis
might be influenced by the retrospective design of the trial, which represents a limitation
to the present study. The setting (ambulatory or hospitalization) was chosen considering
the symptoms, the grade of hemorrhoids, but also the preference of the patient and
the indication of the surgeon, with no randomization. To overcome this limitation,
a further blinded randomized controlled study comparing OH and LA performed in an
ambulatory setting is needed.
A debated topic is recurrence after minimally invasive HD surgery. The two techniques
showed different results regarding long-term recurrence rate. While overall HD recurrence
at 12 months was low and similar in both settings (4.2% in group A vs 3.3% in group
H), when we compared the surgical procedures, recurrence was significantly higher
for LA (6.4% in group A and 7.7% in group H) than OH (1.7% and 0% respectively) ([Table 2]). Hemorrhoidal disease recurrence after 24 months was stable, confirming that recurrence
after LA occurs within 12 months and does not increase further.[17] Compared with the current literature, in which residual or recurrent HD after DGHAL
ranges between 0 and 20%,[11]
[12]
[15]
[16]
[17]
[18]
[19]
[29]
[31]
[32]
[33]
[34] the recurrence rate reported in our study is acceptable and justifies LA as a valid
surgical option for HD even in grade III.
Concerning cost analysis, we highlighted that the total mean institutional costs per
patient were much lower in the ambulatory setting. This can be easily explained as
the office-based procedures were performed under local anesthesia, requiring fewer
professionals and with significant savings of all the costs associated with hospitalization.
Local anesthesia guarantees an excellent relaxation of the anal sphincter,[20] allowing the surgeon to perform the operation under the same conditions obtained
with general or loco-regional anesthesia, but with a lower risk of urinary retention.[21]
[22] Considering the good results reported above, ambulatory surgery for HD showed an
excellent cost-effectiveness ratio and should be contemplated in all Italian institutions
for the treatment of grades II and III HD. Healthcare institutions have an increasing
need for cost savings, so ambulatory surgery is an interesting option for low-complexity
surgery when possible, reserving valuable resources for high- complexity interventions
with the need of hospitalization. Moreover, this approach would enable a wider range
of hospitals to offer hemorrhoid surgery, and especially in peripheral areas.
Conclusions
Our study suggests that HD can be successfully treated in an outpatient facility,
under local anesthesia, and using less aggressive surgery. Both LA and OH techniques
are safe and cost-effective for ambulatory surgical treatment of grades II and III
hemorrhoids; however, a better anatomical correction with only a minimal increase
in pain, no additional morbidity, and low recurrence rate make OH the ideal technique
even in an ambulatory setting.
Trial registration number: UHFerrara130575, approved on 20/06/2013.
The work described has not been published before, but it was selected for oral presentation
at ESCP's 13th Scientific and Annual Meeting that took place 26–28 September 2018
in Nice, France
Ascanelli S, Solari S, Occhionorelli S, Carcoforo P. Impact of office-based surgery
for hemorrhoids on clinical outcome and institutional costs: a prospective controlled
study. Colorectal Dis 2018: 20 (Suppl.4): 6–17.
The work is original and neither published, accepted, or submitted elsewhere, its
publication has been approved by all co-authors, as well as by the responsible authorities
– tacitly or explicitly – at the institute where the work has been performed.
The authors have read and complied with author guidelines.
