A Case Series of Large Volume Iii-Degree Hemorrhoidal Disease: A Special Anatomical Condition Requiring Surgical Treatment

Background: Haemorrhoidal Disease (HD) is common and impacts negatively on quality of life with high socio-economic costs. Despite international guidelines aimed to indicate appropriate care in HD, treatment of III-degree HD remains controversial due to the wide range of ambulatory or surgical procedures available. We aimed to analyse treatment options for III-degree HD focusing on special cases characterized by large volume and/or circumferential presentation of intermittent prolapse or recurrence after conservative treatments. Methods: In the period January 2017- December 2018 out of 152 patients treated by excisional haemorrhoidectomy, we collected a case series of 29 patients affected by III-degree symptomatic HD. They showed a very large, single prolapse or circumferential one or failure of previous conservative treatments. Results: 14 (48.2%) patients (median age 45 yrs.) of our series were recurrence of HD following Rubber Band Ligation (RBL) (5pts), Dearterialization (DEART) (5pts), Stapled Haemorrhoidopexy (SH) (4pts). Mean operative time was 35 min. Postoperative severe pain (6.8%) and urinary retention (17.2%) were the main postoperative complications which did not affect the length of stay. All patients showed a good outcome without any complication at follow-up. Conclusion: III-degree HD shows the highest variability in anatomical presentation, and proposed treatment. Thus, the choice of a personalized approach must rely upon objective evaluation of volume of prolapse. Intermittent prolapse, if very large or circumferential, associated or not to large external haemorrhoids, makes a special condition III degree HD, suggesting surgical excision, avoiding conservative approaches.