Hemorrhoidal disease classification: time to abandon an old paradigm?
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Hemorrhoidal disease classification: time to abandon an old paradigm? F. Gaj1 · A. Trecca2 · D. Passannanti1 · Q. Lai1 Received: 22 July 2020 / Accepted: 3 September 2020 © Springer Nature Switzerland AG 2020
Dear Sir, Hemorrhoidal disease (HD) is one of the most common pathologies worldwide. HD is classified as benign; nevertheless, its social impact is high [1]. However, despite the extensive research done on HD, the most commonly used classification remains the one proposed by Goligher in 1975 [2]. The great success of this classification is probably connected with its simplicity and easy applicability in daily clinical practice. Goligher’s classification is based on the degree of morphological development of the internal hemorrhoids; when internal hemorrhoids prolapse, Goligher defines them as “external hemorrhoids” (Table 1A). This way of dividing hemorrhoids into internal and external ones recognizes the anatomical independence of two vascular plexi, with their different embryological origin, blood supply, and innervation [3]. However, the simplicity of this classification is also its most significant limitation when more sophisticated decisions about treatment have to be made. For example, Goligher’s classification fails to consider the associated symptomatology, the extension, and the dynamic evolution of HD into
the entire hemorrhoidal system, namely both internal and external hemorrhoids. Other critical missing pieces of information in the Goligher classification are the localization of the HD in different quadrants, and the real impact of the disease on patients’ quality of life. Some years ago, we had the opportunity develop a new HD classification able to integrate morphological and clinical aspects of the disease: Position Acute Tone External (PATE) system (Table 1B) [4, 5]. Despite the numerous attempts made by both Italian and non-Italian colleagues, including the PATE classification we first described in 2002 [4, 5], improving or replacing the Goligher classification is more complicated than it might seem. Starting from all of these considerations, we think that a broader consensus is needed to reflect the opinions of the international proctologic community on this topic. Fortyfive years after the Goligher classification was developed, the time has come to make another attempt at classifying this elusive disease with a more precise anatomical description and scoring system that has clinical and therapeutic implications.
* Q. Lai [email protected] 1
Department of General Surgery and Organ Transplantation, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
Operative Endoscopy, Progetto I-Salus, Rome, Italy
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Techniques in Coloproctology
Table 1 Goligher’s (A) and PATE 2006 (B) classifications (A) Goligher’s classification Grade
Definition
I II III
The anal cushions bleed, but do not prolapse The anal cushions prolapse through the anus on staining, but reduce spontaneously The anal cushions prolapse through the anu
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