Determinants Influencing Decision-Making for Operative and Perioperative Management of Grade III and IV Hemorrhoidal Disease: Secondary Analysis of a Multicenter Nationwide Prospective Cohort Study

Purpose: With multiple treatment options available for hemorrhoidal disease (HD), identifying factors that influence surgical and perioperative management decisions is essential, particularly in advanced cases. This study aimed to determine the patient and disease-related determinants affecting the choice of surgical technique and perioperative management in patients with Grade III and IV HD, thereby addressing inter-institutional variations in treatment approaches. Methods: A secondary analysis was performed on data from a nationwide, multicenter prospective cohort study. The study included 315 patients diagnosed with Grade III (72%) and Grade IV (28%) HD, with a mean age of 43.7 ± 11.4 years and a male predominance (76.7%). Preoperative data, including patient demographics, comorbidities (ASA scores), symptom severity, and clinical findings, were collected at participating governmental and private hospitals. Surgical techniques were classified as excisional or non-excisional, while anesthesia type, use of perianal or pudendal analgesia, and hospitalization duration were determined by the surgical teams. Hospital type was also recorded. Multivariable analyses were conducted to identify factors influencing the choice of surgical techniques, anesthesia, analgesia application, and the decision for outpatient procedures. Results: Multivariate analysis revealed that the presence of thrombosis significantly influenced the choice of surgical technique (OR: 7.2, CI: 2.8–12.7, p = 0.001), while hospital category also played an important role (OR: 5.1, CI: 2.7–9.7, p = 0.001). For anesthesia type, factors such as disease grade (OR: 3.3, CI: 1.6–6.7, p = 0.001), hospital category (OR: 9, CI: 4.1–19.9, p < 0.001), and surgical technique (OR: 6.8, CI: 3–15.3, p < 0.001) were significant determinants. The decision to use perianal or pudendal analgesia was influenced by hospital category (OR: 27.1, CI: 11.7–62.6, p < 0.001) and the presence of incontinence (OR: 0.2, CI: 0.04–0.93, p = 0.04). Outpatient management was associated with disease grade (OR: 2.3, CI: 1.1–4.8, p = 0.023), hospital category (OR: 2, CI: 1.2–3.2, p = 0.011), higher comorbidity (ASA ≥ 3, OR: 3.3, CI: 1.8–3.2, p = 0.007), and the selected surgical technique (OR: 3.1, CI: 1.6–5.8, p = 0.001). Conclusion: Significant inter-institutional variations exist in the management of advanced HD. Among various factors, the presence of thrombosis emerges as the predominant determinant in surgical decision-making, providing valuable insights for standardizing treatment protocols and reducing practice variability.