Sclerotherapy with 3% polidocanol foam for third- and fourth-degree hemorrhoids as "bridge treatment" during the COVID-19 pandemic in Italy.

PURPOSE: In Italy, colorectal surgery has been strongly affected with the vast majority (90%) of operations treating benign diseases, with an estimated overall 12-week cancellation rate of 72%. Little is known on how to best manage patients with benign diseases and the consequences this interruption of care will have in post-pandemic times. Proctologic diseases have social, psychological, and healthcare repercussions for their high incidence and great impact on the quality of life.
METHODS: We decided to treated 10 urgent cases affected from III- and IV-degree hemorrhoids with 3% polidocanol foam in attempt to reduce hemorrhoidal symptoms while waiting for surgery so called "bridge treatment".
RESULTS: During the follow-up no complications were occurred, and all patients had resolution of bleeding and pruritus with a mean VAS of 1 (range, 0-1).
CONCLUSIONS: This treatment could reduce the bleeding that is the main symptom from which patients suffer and for which they underwent proctological evaluation and surgery. According to our preliminary experience in the impossibility of accessing the surgery during the COVID-19 pandemic, ST could be considered as the treatment of choice in those patients who are suffering from grade III- and IV-degree hemorrhoids while waiting for surgery.

The SARS-CoV-2 pandemic has become a public health emergency of international concern that also affects patients with anorectal disease, and more than 28 million procedures would be cancelled or rescheduled according to the recent COVIDsurg Collaborative Study [1]. In Italy, the vast majority of operations would be treating benign diseases, with an estimated overall 12-week cancellation rate of 72%. Our hospitals changed dramatically their behavior and only patients with symptomatic and undeferrable neoplastic diseases are allowed to be surgically treated following the SARS-CoV-2 screening program. All outpatient visits and operations of non-oncological patients were suspended, with the exception of highly urgent cases [2, 3]. Little is known on how to best manage patients with benign diseases and especially the consequences this absence of treatment will have in post-pandemic era. As we know, the proctologic diseases have social, psychological, and healthcare repercussions for their high incidence and great impact on the quality of life. During the last 3 months our non-COVID hospital allowed outpatient visits for proctological benign disease although surgery for urgent cases cannot be organized also as a day case procedure and even patients with advanced hemorrhoidal symptoms (III and IV-degree according to Goligher) should be treated conservatively or postponed.

The use of sclerotherapy (ST) with 3% polidocanol foam for hemorrhoidal disease has increased over the years. The main advantages of the sclerotherapy are the cost effectiveness, repeatability, and almost absence of pain although there are no studies concerning the use of foam in the treatment of third- and fourth-degree hemorrhoids [4].

According to the literature, ST with 3% polidocanol foam induces an inflammatory reaction with sclerosis of the submucosal tissue and consequent suspension of the hemorrhoidal tissue. Moreover, the obliteration of the vascular support may lead to reduction in hemorrhoidal volume [5]. We decided to treat 10 urgent cases affected with III- and IV-degree hemorrhoids with 3% polidocanol foam in attempt to reduce hemorrhoidal symptoms while waiting for a surgery the so-called “bridge treatment”. The Visual Analog Scale score was used to assess post-operative pain and patient satisfaction. The symptoms severity was investigated through the Hemorrhoid Severity Score (HSS), at base-line, at 4 weeks after the procedure with telephone interview, and all patients were outpatient evaluated 1 week after the treatment.

The technique was accurately performed as reported by Lobascio P and colleagues with a tangential inclination of the needle, particularly on the anterior pile in the 11 o’clock position, especially in men, in order to avoid prostatic or urinary complications and with the injection above the dentate line to avoid discomfort or pain [5]. All procedures were performed in the outpatient clinic with the patients in the Sims position with no local anesthesia. The post-operative period was uneventful and all patients were discharged 10 min after the treatment. All patients resumed their normal daily activities the day after the procedure. As “bridge treatment”, the endpoint of our procedure was to reduce the hemorrhoids-related symptoms as bleeding and pruritus. During the follow-up, no complications were occurred, and all patients had resolution of bleeding and pruritus with a mean VAS of 1 (range, 0–1).

We are sure this is a preliminary experience in patients with III- and IV-degree hemorrhoids with a short-term follow-up, although some considerations can be made. Firstly, ST with 3% polidocanol foam may be a safe, cost-effective, and repeatable conservative procedure with a good patient satisfaction. Secondly, this treatment could reduce the bleeding that is the main symptom from which patients suffer and for which they underwent proctological evaluation and surgery. According to our preliminary experience in the impossibility of accessing the surgery during the COVID-19 pandemic, ST could be considered the treatment of choice in those patients who are suffering from grade III- and IV-degree hemorrhoids while waiting for surgery although the consequences of this procedure on future hemorrhoidectomy or hemorrhoidopexy are still unknown and certainly deserve to be investigated. We hope this communication can be helpful to other proctologists dealing with proctological patients during this pandemic, wishing these considerations will no longer be necessary in the near future.