March’s Paper of the Month is ‘Guideline for haemorrhoidal disease’ and provides an up to date, practical and clear consensus on the management of this common condition.
European Society of Coloproctology: Guideline for haemorrhoidal disease.
van Tol RR, Kleijnen J, Watson AJM, Jongen J, Altomare DF, Qvist N, Higuero T, Muris JWM, Breukink SO.
Colorectal Dis. 2020 Feb 17. doi: 10.1111/codi.14975. [Epub ahead of print] and on this website.
What is known on the subject?
With over 3500 publications on haemorrhoids in the last 20 years one would expect we would know a great deal about how to treat haemorrhoids. Indeed one might wonder why there is a need for the 5th international guideline to be published in the last 5 years. However, the never ending search for the perfect operation that is both effective, easy to do and harm free (and by that I mainly mean pain free) has resulted in a persistent stream of new techniques and an ever increasing quagmire when it comes to interpreting the literature to find out what is best for the patient.
What this paper adds
Whilst this is one of several recent guidelines, it is the most methodologically robust and the first to follow the AGREE II checklist. The methodology is not perfect but the publication does attempt to represent the views of a truly European consensus and sets a standard for future haemorrhoid guidelines. The outcomes are extensive with 34 recommendations formulated over 6 sections. However, a treatment algorithm condenses these recommendations.
Implications for colorectal practice
The summary treatment algorithm encapsulates the document well. In brief this highlights the importance of initial conservative therapy and reassurance before targeted therapy based on degree of prolapse whilst taking into account what the patient wants in terms of outcome. It can be utilised as the current gold standard for treatment of these patients. If the ESCP can ensure the guidelines are maintained and updated regularly this will remain the ‘go to’ document for clinicians treating haemorrhoids.
Steven Brown
Professor of Surgery, Sheffield Teaching Hospitals and Sheffield University, UK