{"id":10273,"date":"2026-04-09T10:20:24","date_gmt":"2026-04-09T10:20:24","guid":{"rendered":"https:\/\/www.proefschriftmaken.nl\/portfolio\/robin-van-tol\/"},"modified":"2026-04-23T07:36:03","modified_gmt":"2026-04-23T07:36:03","slug":"robin-van-tol","status":"publish","type":"us_portfolio","link":"https:\/\/www.proefschriftmaken.nl\/en\/portfolio\/robin-van-tol\/","title":{"rendered":"Robin Van Tol"},"content":{"rendered":"","protected":false},"excerpt":{"rendered":"","protected":false},"author":8,"featured_media":12764,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"us_portfolio_category":[45],"class_list":["post-10273","us_portfolio","type-us_portfolio","status-publish","has-post-thumbnail","hentry","us_portfolio_category-new-template"],"acf":{"naam_van_het_proefschift":"The Old, the New and the Ever-Changing View of Haemorrhoidal Disease Research","samenvatting":"Dit proefschrift is geschreven met twee doelen:\n\n1. Het eerste doel van het proefschrift was om de heterogeniteit in onderzoeksuitkomsten aan te pakken in hemorrhoiden onderzoek en om oplossingen te vinden om de homogeniteit in de rapportage van de resultaten te verbeteren.\n2. Het tweede doel was het opstellen en ontwikkelen van een internationale multidisciplinaire richtlijn voor de behandeling van hemorrhoiden.\n\nHemorrhoiden is een van de meest voorkomende anorectale aandoeningen. De werkelijke prevalentie van aambeien is echter niet bekend; ziekenhuisstudies zijn niet representatief voor de totale populatie met hemorrhoiden en community-gebaseerde studies hebben alleen op zelfrapportage vertrouwd. Dit heeft leid tot gerapporteerde prevalentiepercentages vari\u00ebrend van 4,4-45% (1-4). In Nederland wordt de prevalentie geschat op ongeveer 8,6 per 1000 personen. De piek incidentie lijkt tussen de leeftijd van 45-65 jaar te liggen (5, 6). In de algemene bevolking is de prevalentie vergelijkbaar bij mannen en vrouwen (2, 7). Hoge oestrogeenreceptorniveaus zijn ge\u00efdentificeerd in aambeien, wat hemorro\u00efdale symptomen tijdens de zwangerschap kan verklaren (8). Er is een verhoogde prevalentie onder hogere sociaaleconomische groepen, maar dit kan gezondheidsgerelateerd gedrag weerspiegelen (9).\n\nMet de voortdurende evolutie van verschillende behandelingen voor de zorg van hemorrhoiden is het belangrijk dat de effectiviteit van (chirurgische) behandelingen op een systematische manier wordt geanalyseerd. Klinische onderzoeken naar de effectiviteit van interventies voor hemorrhoiden hebben een breed scala aan uitkomsten en uitkomstmaten gebruikt. Verschillende richtlijnen wezen op het gebrek aan uniformiteit van de definitie, meting en rapportage van uitkomsten. Hierdoor wordt optimale bewijssynthese belemmerd en ontbreken richtlijnen van hoge kwaliteit (10-12).\n\nEen oplossing om de homogeniteit in de resultaat rapportage over hemorrhoiden te verbeteren, is het ontwikkelen en gebruiken van een gestandaardiseerde uitkomstenset. Een uitkomstenset vertegenwoordigt een uit consensus verkregen minimale set uitkomstparameters die moet worden gerapporteerd in alle studies die over een bepaalde aandoening rapporteren (13). Een overeengekomen uitkomstenset zal het vermogen verbeteren om toekomstige studies te vergelijken en om een optimaal behandelingsalgoritme voor hemorrhoiden te ontwikkelen. Aangezien er nog geen uitkomstenset voor hemorrhoiden bestaat, is een belangrijke stap voor het verbeteren van hemorrhoiden onderzoek de ontwikkeling van een gestandaardiseerde uitkomstenset voor dergelijk onderzoek.\n\nDe afgelopen tien jaar zijn verschillende nationale richtlijnen voor de behandeling van hemorrhoiden gepubliceerd (35-37). De meest recent bijgewerkte richtlijn is van de Amerikaanse colorectale chirurgen (14). De methodologische kwaliteit van deze richtlijnen kan worden verbeterd door veel specifieker te zijn over de methoden die worden gebruikt om hun aanbevelingen te formuleren. Daarom willen we een internationale, multidisciplinaire, hoogwaardige richtlijn ontwikkelen in samenwerking met de European Society of Coloproctology (ESCP) die zowel diagnostische als therapeutische modaliteiten voor het beheer van hemorrhoiden aanpakt.\n\nDoel 1\n\nHoofdstuk 2: een protocol voor het ontwikkelen van een gestandaardiseerde uitkomstenset voor hemorrhoiden.\nHoofdstuk 3: literatuuroverzicht van de verschillende uitkomsten in hemorrhoiden studies\nHoofdstuk 4: een Delphi proces om een internationale uitkomstenset te ontwikkelen voor hemorrhoiden.\nHoofdstuk 5: een kwalitatieve studie naar de ervaringen van patienten met hemorrhoiden.\n\nDoel 2\n\nHoofdstuk 6: een nationale enquete naar het behandelalgoritme onder de Nederlandse chirurgen.\nHoofdstuk 7: de richtlijn van hemorrhoiden.\nBijlage: de methodiek achter de richtlijn.\n\nVoor de ontwikkeling van een gestandaardiseerde uitkomstenset moet een stapsgewijze aanpak worden gevolgd die in een protocol wordt beschreven (hoofdstuk 2). Een van de eerste pogingen om de resultaten te standaardiseren werd in de jaren zeventig door de Wereldgezondheidsorganisatie uitgevoerd met betrekking tot kankeronderzoeken. Dit resulteerde in een WHO-handboek met richtlijnen die de minimumvereisten voor gegevensverzameling in kankeronderzoek aanbevelen (15). Het meest opmerkelijke werk tot nu toe met betrekking tot standaardisatie van resultaten sindsdien is uitgevoerd door de OMERACT-samenwerking (Outcome Measures in Rheumatology) (16). Sinds OMERACT zijn er andere voorbeelden (d.w.z. HOME, IMMPACT) van vergelijkbare initiatieven om aanbevelingen te ontwikkelen over de resultaten die in klinische onderzoeken moeten worden gemeten (17, 18). De OMERACT-gemeenschap heeft echter onlangs de OMERACT-filter 2.0 gepubliceerd, die een zorgvuldige uitleg geeft over hoe deze in andere subspecialiteiten kan worden ge\u00efmplementeerd (19).\n\nIn dit proefschrift hebben we besloten deze methode te volgen. In navolging van het OMERACT-initiatief is de eerste fase bij het ontwikkelen van een uitkomstenset een literatuuronderzoek naar de soorten uitkomsten en uitkomstmaten die zijn gebruikt in eerder gepubliceerd onderzoek naar hemorrhoiden (hoofdstuk 3). In hemorrhoiden onderzoek worden verschillende uitkomsten (bijvoorbeeld verzakking, recidief, complicaties en duur van de operatie) gebruikt als primaire en secundaire uitkomsten. Deze heterogeniteit in de rapportage van uitkomsten bemoeilijkt de juiste vergelijking tussen onderzoeken. Zelfs twee recent uitgevoerde gerandomiseerde gecontroleerde studies van een onderzoeksgroep uit Engeland gebruiken verschillende primaire uitkomsten. In de eerste studie, de HubBLe-studie, wordt rubber band ligatie (RBL) vergeleken met de doppler (DG-HAL). De auteurs gebruiken \u2018herhaling na \u00e9\u00e9n jaar na de procedure\u2019 als primaire uitkomst. De tweede studie, de eTHoS-studie, waarbij geniete hemorro\u00efdopexy wordt vergeleken met de traditionele hemorro\u00efdectomie, wordt \u2018een gebied onder de curve van de kwaliteit van leven\u2019 gemeten als primaire uitkomst met behulp van het beschrijvende systeem EQ-5D-3L (20-22).\n\nDe tweede fase bij het ontwikkelen van een uitkomstenset is een Delphi proces. Eerst zullen de resultaten die in de literatuurstudie zijn ge\u00efdentificeerd, worden geoperationaliseerd in een vragenlijst voor artsen en een afzonderlijke vragenlijst voor pati\u00ebnten. Daarna volgen twee opeenvolgende rondes van de vragenlijst om deze uitkomsten te prioriteren. Fase drie bestaat uit een vergadering met artsen om overeenstemming te bereiken over de eindpunten van de uitkomstenset. Dit wordt beschreven in hoofdstuk 4.\n\nDoor een uitkomstenset voor hemorrhoiden te ontwikkelen, moeten we echter voorzichtig zijn dat behandelvoorkeuren en -uitkomsten aanzienlijk kunnen verschillen tussen pati\u00ebnten met hemorrhoiden (23). Kwalitatieve interviews bij pati\u00ebnten met hemorrhoiden kunnen worden uitgevoerd om een dieper inzicht te krijgen en rechtstreeks van de pati\u00ebnten informatie te verkrijgen over hun ervaringen met hemorrhoiden en behandelingsvoorkeuren (hoofdstuk 5) (24, 25).\n\nRichtlijnen dienen het doel om klinische (gedeelde) besluitvorming met betrekking tot behandelingskeuzes te ondersteunen, volgens het beste beschikbare bewijs. Verschillende nationale HD-richtlijnen zijn gepubliceerd (14, 26, 27). De Nederlandse richtlijn is in 2015 gepubliceerd. Om de huidige praktijk in de behandeling van hemorrhoiden in Nederland te verkennen voordat een internationale richtlijn wordt ge\u00efntroduceerd, zullen we een nationale enqu\u00eate onder Nederlandse colorectale consultants, fellows en arts-assistenten uitvoeren (hoofdstuk 6). Deze resultaten dienen als richting voor de volgende fase van het ontwikkelen van een internationale richtlijn voor hemorrhoiden.\n\nVerschillende initiatieven (d.w.z. NICE, GIN-McMaster) ontwikkelden checklists voor de ontwikkeling van richtlijnen en beschreven dat een richtlijn moet worden ontwikkeld volgens een proces dat begint bij het gekozen onderwerp en zich uitstrekt tot toekomstige updates van richtlijnen. De AGREE Enterprise ontwikkelde het AGREE-instrument, een online tool om de kwaliteit en rapportage van praktijkrichtlijnen te beoordelen (28). Bestaande hemorrhoiden richtlijnen beschrijven geen duidelijke ontwikkelingsmethode zoals voorgesteld door de AGREE-checklist. Ze rapporteren vaak hun beoordelingsvragen en methoden voor het formuleren van hun aanbevelingen niet. In samenwerking met de European Society of Coloproctology (ESCP) zal een internationale kwaliteitsrichtlijn voor hemorrhoiden worden ontworpen. In hoofdstuk 7 worden de resultaten van de definitieve ESCP richtlijn voor de behandeling van hemorrhoiden gepresenteerd. In de bijlage worden de ontwikkelingsprocessen en -methoden volgens het AGREE II-instrument beschreven.","summary":"This thesis consisted of two aims. The first aim of this thesis was to address heterogeneity in study outcomes in haemorrhoidal disease (HD) research and find solutions to improve homogeneity in outcome reporting. The second aim was to prepare and develop an international, high quality, multidisciplinary guideline for HD.\n\nSystematic reviews of the effectiveness of HD treatments highlighted the lack of uniform outcome definition, -measurement and -reporting in research data, hindering optimal evidence synthesis (1-3). A solution to improve homogeneity in outcome reporting was the development of a Core Outcome Set (COS). A COS represents a consensus-derived minimum set of outcome parameters that should be reported in all studies that report on a particular condition (4). Since no COS for HD existed yet, a logical next step was the development of such a COS for HD.\n\nA detailed protocol (chapter 2) described the development process of the COS consisting of two main phases: 1) a literature review to ascertain which outcomes are commonly used in clinical trials for HD and 2) a consensus study according to the Delphi methodology. Additionally, qualitative interviews (chapter 5) were conducted to gain a deeper understanding and obtain information directly from the patients about their experiences with HD and treatment preferences (5, 6).\n\nFor the literature review (chapter 3) Medline (Pubmed), Embase (OVID) and Cochrane were searched for interventional studies for adult patients with HD. Two authors independently identified and reviewed eligible studies and finally 34 studies were included. The outcomes used in the studies were categorized according to the framework of OMERACT 2.0 filter (7, 8) a practical framework to develop and validate domains and outcomes for any health condition (9). This resulted in three Core Areas, 10 Domains and 59 different types of outcomes. Core Areas included Life impact, Pathophysiological manifestations, Resource use\/economic impact and Death. No outcome could be placed into the Core Area Death. Apparently, death was not an outcome of interest in HD studies.\n\nThe Core Area Life impact included the following three Domains: patient satisfaction, time to return to normal and quality of life. The Core Area Pathophysiological manifestations consisted of three Domains: symptoms, complications and recurrence. The Core Area Resource use\/ economical impact included four Domains: duration of operation, duration of hospitalization, re-operation and costs. The most reported Domains were symptoms (100%), complications (91%), recurrence (59%) and patient satisfaction (41%) [table 1,2 and 3].\n\nTable 1: Outcome Domains in 42 studies included according to OMERACT 2.0 filter Core \u2018\u2019Life impact\u2019\u2019\n\nDomain within Domain | Number of outcomes reported within Domain | Number of studies reporting outcomes in Domain (%)\nPatient satisfaction | 1 | 14 (41)\nTime to return to normal | 6 | 12 (35)\nQuality of life | 2 | 8 (24)\n\nTable 2: Outcome Domains in 42 studies included according to OMERACT 2.0 filter Core \u2018\u2019Pathophysiological manifestations\u2019\u2019\n\nDomain within domain | Number of outcomes reported within domain | Number of studies reporting outcomes in Domain (%)\nSymptoms | 22 | 34 (100)\nComplications | 18 | 31 (91)\nRecurrence | 2 | 20 (59)\n\nTable 3: Outcome Domains in 42 studies included according to OMERACT 2.0 filter Core \u2018\u2019Resource use\/ economical impact\u2019\u2019\n\nDomain within domain | Number of outcomes reported within domain | Number of studies reporting outcomes in Domain (%)\nDuration of operation | 3 | 10 (29)\nDuration of hospitalization | 2 | 13 (38)\nRe-operation | 2 | 13 (38)\nCosts | 1 | 5 (15)\n\nTwenty-two different outcomes were used in the Domain \u2018symptoms\u2019. Most reported outcomes were pain (91%), blood loss (94%) and prolapse (71%). Eighteen different outcomes were used in the Domain \u2018complications\u2019. Recurrence was used in 20 studies (59%). Patient satisfaction was used in 14 studies (41%) using non-validated questionnaires. On average, 5.8 different outcomes (2-8) were assessed per study. With this review, we derived potentially relevant Domains and Outcomes for the development of a COS for HD (47).\n\nFor the COS development, the Delphi methodology was followed (chapter 4). In collaboration with the European Society of Coloproctology (ESCP) 43 national representatives were invited to participate in the study. Besides, Dutch-speaking male and female participants (>18 years) (n=30) having HD were asked to participate in the study. The Delphi process consisted of four phases.\n\nIn phase one, the outcomes, which were identified in the literature review (10), were operationalized into a questionnaire for healthcare professionals and a separate questionnaire for patients.\n\nPhase two involved two sequential rounds of the questionnaire for healthcare professionals and one patient round, aiming to prioritize the different outcomes (11). Participants were asked to rate the appropriateness of each Domain and Outcome on a 9-point Likert scale. In round one, the first part of the questionnaire regarding the question \u2018What domains should we use as primary and secondary end-points in the COS for HD?\u2019, the domains (in order of level of appropriateness) \u2018symptoms\u2019, \u2018patient satisfaction\u2019, \u2018recurrence\u2019, \u2018complications\u2019, \u2018prolapse\u2019 and \u2018pain\u2019 were rated appropriate as primary end-point options. In the same round, the domains \u2018patient satisfaction\u2019, \u2018complications\u2019 and \u2018recurrence\u2019 were rated as appropriate as secondary end-points and \u2018symptoms\u2019, \u2018prolapse\u2019 and \u2018pain\u2019 were rated as unsure. In the second part of questionnaire, regarding the question \u2018Which outcomes should be included in the domains?\u2019, most outcomes (i.e. \u2018pain\u2019, \u2018prolapse\u2019, \u2018itching\u2019, \u2018soiling\u2019, \u2018blood loss\u2019, \u2018abscess\u2019, \u2018incontinence\u2019, \u2018anal stenosis\u2019, \u2018stricture\u2019, \u2018fistula\u2019, \u2018severe bleeding\u2019, \u2018severe pain\u2019, \u2018urinary retention\u2019, \u2018thrombosis\u2019) were rated as appropriate. The Outcomes \u2018urgency\u2019 and \u2018constipation\u2019 were rated as unsure. The Outcomes \u2018edema\u2019 and \u2018nodule\u2019 were rated as inappropriate and were omitted.\n\nThe following definitions of recurrence were rated as appropriate: \u2018recurrent prolapse after a symptom free period\u2019, \u2018reappearance of initial symptoms\u2019 and \u2018further intervention necessary\u2019. The definition \u2018residual symptoms in relation to degree of satisfaction\u2019 was rated as unsure and \u2018histological proved recurrence\u2019 was rated as inappropriate. In round two, healthcare professionals rated the Domains \u2018symptoms\u2019, \u2018patient satisfaction\u2019, \u2018recurrence\u2019 and \u2018complications\u2019 as primary endpoints. As secondary endpoints, all Domains (i.e. \u2018patient satisfaction\u2019, \u2018recurrence\u2019, \u2018prolapse\u2019, \u2018complications\u2019, \u2018symptoms\u2019 and \u2018pain\u2019) were rated as appropriate. Regarding the question: \u201cWhich Outcomes should be included in the Domains\u201d, \u2018constipation\u2019, \u2018urgency\u2019, \u2018urinary retention\u2019 and \u2018thrombosis\u2019 were rated as unsure. \u2018Pain\u2019, \u2018prolapse\u2019, \u2018itching\u2019, \u2018soiling\u2019, \u2018blood loss\u2019, \u2018abscess\u2019, \u2018incontinence\u2019, \u2018anal stenosis\u2019, \u2018fistula\u2019, \u2018stricture\u2019, \u2018severe pain\u2019 and \u2018severe bleeding\u2019 were rated as appropriate outcomes.\n\nTo define recurrence the following options were rated as appropriate: \u2018further intervention necessary\u2019, \u2018recurrent prolapse after symptom free period\u2019, \u2018reappearance of initial symptoms\u2019, and \u2018residual symptoms in relation to degree of satisfaction\u2019. In conclusion, the questionnaire rounds did not result in a clear-cut selection of primary and secondary endpoints for HD. Most Domains and Outcomes were considered important and only three Outcomes were excluded. Patients rated \u2018symptoms\u2019 as most important to discuss during the outpatient clinic. They reported the following complaints: \u2018pain\u2019, \u2018prolapse\u2019, \u2018itching\u2019, \u2018soiling\u2019 and \u2018blood loss\u2019.\n\nIn phase three a face-to-face consensus meeting was conducted with 16 healthcare professionals in order to get consensus on the final endpoints of the COS [table 4]. Healthcare professionals rated the Domain \u2018symptoms\u2019 as the most appropriate primary endpoint in the COS. Further, healthcare professionals reached consensus that the Domains \u2018complications\u2019, \u2018recurrence\u2019 and \u2018patient satisfaction\u2019 should all be used as secondary endpoints in the COS for HD.\n\nBesides uniformity in reporting, this Delphi study underlined the need to integrate Patient Reported Outcome Measures (PROMs) next to traditional clinical outcomes. PROMs have become an increasingly important component of assessing treatment response. Healthcare professionals agreed that the Domain \u2018symptoms\u2019 should be a Patient Reported Outcome Measure (PROM) and include the Outcomes \u2018pain\u2019, \u2018prolapse\u2019, \u2018itching\u2019, \u2018soiling\u2019 and \u2018blood loss\u2019.\n\nIn phase four a short survey was sent to the healthcare professionals in order to reach consensus on \u2018how\u2019 the selected endpoints should be assessed and at which time points pre- and post-procedure. \u2018Incontinence\u2019 should be assessed by the Wexner Fecal Incontinence Score, \u2018abscess\u2019 by physical examination, \u2018urinary retention\u2019 by ultrasonography, \u2018anal stenosis\u2019 by physical examination, and \u2018fistula\u2019 by MR-imaging if physical examination is inconclusive [table 4]. During follow-up, the Outcome \u2018symptoms\u2019 should be assessed at baseline (i.e. before the procedure) and at 7 days, 6 weeks (arguably by telephone) and one-year post-procedure. The Outcomes \u2018abscess\u2019 and \u2018urinary retention\u2019 should be assessed 7 days\u2019 post-procedure, and \u2018rectal stenosis\u2019, \u2018incontinence\u2019 and \u2018fistula\u2019 one year post-procedure [table 5].\n\nThis resulted in the first international COS for HD based on an international Delphi study. Use of this COS will improve the quality and uniformity of future research and enhance evidence synthesis for meta-analyses and guidelines.\n\nTable 4: of the core Domains for haemorrhoidal disease\n\nCore Outcome Set\nPRIMARY OUTCOME\n\u2022 Patient reported symptoms: Patient Reported Outcome Measure (PROM)\n\u2022 Blood loss\n\u2022 Pain\n\u2022 Prolapse\n\u2022 Itching\n\u2022 Soiling\nSECONDARY OUTCOME\n\u2022 Complications\n\u2022 Incontinence: Wexner Fecal Incontinence Score\n\u2022 Abscess: Physical examination\n\u2022 Fistula: MR imaging after inconclusive physical examination\n\u2022 Urinary retention: Ultrasonography\n\u2022 Anal stenosis: Physical examination\n\u2022 Recurrence: The reappearance of initial symptoms\n\u2022 Patient satisfaction: This endpoint will be included in the PROM.\n\nTable 5: Follow-up scheme.\n\nOutcomes | Baseline | 7 days | 6 weeks | 1 year\nPrimary endpoint: Symptoms (PROM) | X | X | X | X\nSecondary endpoints:\nAbscess | X\nUrinary retention | X\nAnal stenosis | X\nIncontinence | X\nFistula | X\n\nSince these traditional clinical outcomes \u2013 mostly selected by healthcare professionals - may not include all relevant benefits and harms as experienced by patients. However, differences in such preferences are difficult to predict and may vary between conditions (21-25).\n\nDuring individual interviews (n=15), patients were encouraged to describe their experiences and symptoms they encounter having HD. Blood loss and anal pain were the most commonly reported symptoms. Participants indicated that these symptoms were directly associated with emotional burden, daily adjustments, and social impact. For example, in patients having blood loss before the diagnosis was known, this symptom resulted in feelings of fear. Besides, blood loss resulted in embarrassment and avoidance of social activities. Participants were not always completely satisfied with the process and outcomes of treatment. They expected greater openness and exchange of information regarding the different treatment options and the expected outcomes from their healthcare professionals.\n\nThis was the first study that showed that certain aspects relevant to the patient were overlooked when HD-treatment effectiveness was assessed by only traditional endpoints such as prolapse, recurrence and complications. Furthermore, this study showed that patients had different preferences regarding the treatment options compared to the preferences of the clinician.\n\nIn the second part of the thesis the development of the first international guideline for HD in collaboration with the European Society of Coloproctology (ESCP) is described. Up till now, only country-specific guidelines have been published, including the American Society of Colon and Rectal Surgeons guideline (12), the Italian (13)- and the French HD guideline (14). The methodological quality of these guidelines could be improved by being much more specific regarding the methods used to formulate the recommendations.\n\nTo see how the current Dutch situation was before the introduction of the new guideline, a nationwide survey (chapter 6) was conducted using a validated web based program. The survey was distributed among 619 officially registered Dutch colorectal consultants, fellows and residents and contained questions regarding the treatment options for each grade of HD.\n\nGrade I and II HD were most often treated conservatively or with Rubber Band Ligation (RBL). Respondents chose for more invasive treatment options like Doppler-Guided Haemorrhoidal Artery Ligation (DG-HAL), stapled haemorrhoidopexy and haemorrhoidectomy in case of grade III and IV HD. In case of recurrent HD, they often preferred basic treatment and RBL. This study showed that there is considerable variability in treatment of HD in the Netherlands.\n\nIn a protocol (addendum) the seven steps of the guideline development were described using the AGREE II instrument [21]. We started with defining the scope of the guideline in phase one. The target group of the guideline consisted of all physicians treating patients with HD, healthcare workers and patients who desire information regarding the treatment management of HD. The patient population included patients with all stages of HD. The guideline needed to address both the diagnostic and therapeutic modalities for HD management.\n\nIn phase two the guideline development group (GDG) was composed and consisted of five colorectal surgeons, one gastroenterologist and proctologist (TH), one general practitioner (JM) specializing in the treatment of HD, one surgical resident (RT) and one methodologist (JK) with extensive experience in guideline development.\n\nIn phase three the first set of review questions were developed. The review questions were built up using a reversed process, starting with possible recommendations based on the GDG\u2019s knowledge.\n\nIn phase four a literature search was performed in MEDLINE (Ovid), PubMed, EMBASE (Ovid), and the Cochrane Database of Systematic Reviews. The search was focused on existing systematic reviews addressing each review question, supplemented by other studies published after the time frame covered by the systematic reviews.\n\nIn phase five data of the included papers were extracted by the surgical resident (RT) and checked by the methodologist (JK) and the GDG.\n\nIn phase six the GDG decided what recommendations could be made based on the evidence found in literature. GRADE was used to indicate the quality of the evidence (15).\n\nThis resulted in the first international guideline for HD (chapter 7) including 34 recommendations covering six sections: 1) evaluation: symptoms, diagnosis & classification, 2) basic treatment, 3) outpatient procedures, 4) surgical interventions, 5) special situations and 6) other surgical techniques [figure 1].\n\nFor grade I and II HD, RBL appears to be the treatment of choice, because patients who undergo RBL showed a significantly better response compared to patients treated with sclerotherapy (SCL) and\/or infrared coagulation (IRC). Besides patients treated by RBL have significantly less recurrence compared to patients treated with SCL or IRC. IRC may be the first treatment option in bleeding grade I HD because it causes less pain and complications (16). However, complication rates were similar in higher grade HD between RBL, IRC and SCL (17-19).\n\nFor grade III and IV HD, haemorrhoidectomy remains the treatment of choice. Comparing stapled haemorrhoidopexy (SH) and haemorrhoidectomy, the efficacy of SH is generally lower than haemorrhoidectomy (20), especially in grade IV HD (20). The DG-HAL + mucopexy may be considered in patients with grade II-III HD. However, more research regarding this technique is necessary. The additional effect of the Doppler is currently being questioned since two studies showed that significantly more complications and unscheduled postoperative events were reported in the DG-HAL + mucopexy group compared to the mucopexy alone group (21, 22).\n\nThe flow diagram for all degrees of haemorrhoids is shown below (figure 1). This international multidisciplinary guideline provides an up to date and evidence based and may serve as a useful guidance for patients and clinicians.\n\nFigure 1: flow diagram grade I-IV HD.","auteur":"Robin Van Tol","auteur_slug":"robin-van-tol","publicatiedatum":"23 april 2020","taal":"EN","url_flipbook":"https:\/\/ebook.proefschriftmaken.nl\/ebook\/robinvantol?iframe=true","url_download_pdf":"https:\/\/ebook.proefschriftmaken.nl\/download\/1031a65e-96ab-4c8c-88ff-17d9be1d8194\/optimized","url_epub":"","ordernummer":"FTP-202604091015","isbn":"","doi_nummer":"","naam_universiteit":"Overig","afbeeldingen":12764,"naam_student:":"","binnenwerk":"","universiteit":"Overig","cover":"","afwerking":"","cover_afwerking":"","design":""},"_links":{"self":[{"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/us_portfolio\/10273","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/us_portfolio"}],"about":[{"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/types\/us_portfolio"}],"author":[{"embeddable":true,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/users\/8"}],"replies":[{"embeddable":true,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/comments?post=10273"}],"version-history":[{"count":1,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/us_portfolio\/10273\/revisions"}],"predecessor-version":[{"id":10276,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/us_portfolio\/10273\/revisions\/10276"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/media\/12764"}],"wp:attachment":[{"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/media?parent=10273"}],"wp:term":[{"taxonomy":"us_portfolio_category","embeddable":true,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/us_portfolio_category?post=10273"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}