LAUSR

We thank Dr. Biondo, Dr. Bashir, and colleagues for their comments [1, 2]. Pain is a subjective perception. The maximal pain level of the day will of course affect the perception of the average pain level of the day, and the time of maximal pain perceived by different patients might be quite different; therefore, we assessed the average daily pain. This mean pain score is a better reflection of the pain experienced in the first postoperative week. The primary endpoint of the study was the difference in pain score. The difference in pain score of 1.5 (on a scale of 1–10) is derived from previously published studies [3, 4]. Our aim in referencing a retrospective study on total hemorrhoidal dearterialization (THD) versus stapled hemorrhoidopexy done by our centre is not to show how the study influenced our power calculations. Our aim was to point out that previous reports showed that THD is associated with less postoperative pain than stapled hemorrhoidopexy and in the current study we wanted to find out whether tissueselecting technique (TST) may have overcome this potential disadvantage of stapled hemorrhoidopexy. As far as the completeness of the follow-up, this is because all patients were from Hong Kong and Hong Kong is a small place. If the patient defaulted to follow-up, it is easy for us to call the patients to come back for assessment. As regards anesthesia and pain management, all the operations were done under general anesthesia. Our usual practice is to use acetaminophen and tramadol, a weak opioid, rather than nonsteroidal anti-inflammatory drugs (NSAIDs) for pain control, as THD and TST are both minimally invasive methods for treating hemorrhoids and severe pain is not expected. Moreover, NSAIDs have side effects like gastrointestinal bleeding. Unfortunately, we did not prospectively record the number of mucopexies. Although mucopexy might increase pain in THD, we used TST to treat the group of patients with a similar prolapse score; this is a fair comparison between the two groups. In the management of hemorrhoids, the most important factor is whether patients think they are cured or not. We assessed the postoperative symptoms with the symptom score. We only performed additional procedures for the symptomatic patients. In every treatment of hemorrhoids, blood loss is not expected to be significant and it is not the main concern for the comparison of THD and TST. As far as return to normal activities, the mean age of both groups of patients was 50 years. Some of the patients were housewives, retired people, or unemployed, and we assessed both social and professional activities. A return to normal activities did not necessarily mean that they went back to work. Dr. Bashir mentioned that in the literature that recurrence rates of THD range from 10 to 21%. More recently, the Hubble trial in 2016 [5], a multicenter, open-label, parallel group, randomised controlled trial which included patients from 17 UK NHS trusts, compared rubber band ligation with THD for grade II or early grade III hemorrhoids. At 1 year after surgery, the recurrence in the THD group was as high as 30% (48 of 161 patients) and THD was as effective as rubber band ligation. To the reason why our current results are so different from our previous retrospective study [6] is because this was comparing THD and stapled hemorrhoidopexy done from February 2012 to July 2013, which only reported symptom scores up to 4 months postoperatively. In our current study, symptom scores up to 1 year postoperatively were reported. Secondly, in the previous study, recurrence was not well defined. In the current study, we used the need to undergo further treatment, including rubber band ligation or * L. H. Leung [email protected]