Optimizing the treatment for anorectal disease Surgical and patient-reported outcomes

This thesis focuses on optimizing treatment strategies for two prevalent benign anorectal conditions: hemorrhoidal disease and cryptoglandular perianal fistulas. It emphasizes the importance of integrating surgical outcomes with patient-reported experiences to improve clinical decision-making and personalized care.
Part I evaluates the management of hemorrhoidal disease. The HOLLAND trial compared rubber band ligation (RBL) with hemorrhoidectomy for grade III hemorrhoids, revealing that hemorrhoidectomy provided superior long-term symptom relief, improved quality of life, and lower recurrence, though it was associated with higher morbidity and costs. A cost-effectiveness analysis highlighted that its value depends on willingness-to-pay thresholds. Additionally, the thesis critically assessed the Goligher classification, revealing its limitations and advocating for symptom-based alternatives that better reflect disease burden.
Part II explores the prevention and treatment of cryptoglandular perianal fistulas. The ATLAS trial investigates the role of postoperative antibiotics in preventing fistula formation following surgical drainage of a perianal abscess. Novel use of 3D high-resolution anorectal manometry (3D-HRAM) was explored, though its clinical utility in predicting continence outcomes after fistula surgery remains inconclusive. Long-term follow-up studies of sphincter-sparing techniques (LIFT and advancement flap) demonstrated high recurrence and continence deterioration, underscoring the need for careful patient selection and informed counseling. A pilot study of the Semiflex catheter showed potential for integration in multimodal strategies, though feasibility targets were not fully met.
Altogether, this thesis advocates for patient-centered, evidence-based approaches in anorectal disease management, highlighting the need for standardized outcome measures and pragmatic trial designs to guide future research and clinical practice.