***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: Background Current st and ard for most of the locally advanced rectal cancers is preoperative chemoradiotherapy , and , variably per institution , postoperative adjuvant chemotherapy . Short-course preoperative radiation with delayed surgery has been shown to induce tumour down-staging in both r and omized and observational studies . The concept of neo-adjuvant chemotherapy has been proven successful in gastric cancer , hepatic metastases from colorectal cancer and is currently tested in primary colon cancer . Methods and design Patients with rectal cancer with high risk features for local or systemic failure on magnetic resonance imaging are r and omized to either a st and ard arm or an experimental arm . The st and ard arm consists of chemoradiation ( 1.8 Gy x 25 or 2 Gy x 25 with capecitabine ) preoperatively , followed by selective postoperative adjuvant chemotherapy . Postoperative chemotherapy is optional and may be omitted by participating institutions . The experimental arm includes short-course radiotherapy ( 5 Gy x 5 ) followed by full-dose chemotherapy ( capecitabine and oxaliplatin ) in 6 cycles before surgery . In the experimental arm , no postoperative chemotherapy is prescribed . Surgery is performed according to TME principles in both study arms . The hypothesis is that short-course radiotherapy with neo-adjuvant chemotherapy increases disease-free and overall survival without compromising local control . Primary end-point is disease-free survival at 3 years . Secondary endpoints include overall survival , local control , toxicity profile , and treatment completion rate , rate of pathological complete response and microscopically radical resection , and quality of life . Discussion Following the advances in rectal cancer management , increased focus on survival rather than only on local control is now justified . In an experimental arm , short-course radiotherapy is combined with full-dose chemotherapy preoperatively , an alternative that offers advantages compared to concomitant chemoradiotherapy with or without postoperative chemotherapy . In a multi-centre setting this regimen is compared to current st and ard with the aim of improving survival for patients with locally advanced rectal cancer . Trial registration Clinical Trials.gov Summary Background Two commonly performed surgical interventions are available for severe ( grade II – IV ) haemorrhoids ;  traditional excisional surgery and stapled haemorrhoidopexy . Uncertainty exists as to which is most effective . The eTHoS trial was design ed to establish the clinical effectiveness and cost-effectiveness of stapled haemorrhoidopexy compared with traditional excisional surgery . Methods The eTHoS trial was a large , open-label , multicentre , parallel-group , pragmatic r and omised controlled trial done in adult participants ( aged 18 years or older ) referred to hospital for surgical treatment for grade II – IV haemorrhoids . Participants were r and omly assigned ( 1:1 ) to receive either traditional excisional surgery or stapled haemorrhoidopexy . R and omisation was minimised according to baseline EuroQol 5 dimensions 3 level score ( EQ-5D-3L ) , haemorrhoid grade , sex , and centre with an automated system to stapled haemorrhoidopexy or traditional excisional surgery . The primary outcome was area under the quality of life curve ( AUC ) measured with the EQ-5D-3L descriptive system over 24 months , assessed according to the r and omised groups . The primary outcome measure was analysed using linear regression with adjustment for the minimisation variables . This trial is registered with the IS RCT N registry , number IS RCT N80061723 . Findings Between Jan 13 , 2011 , and Aug 1 , 2014 , 777 patients were r and omised ( 389 to receive  stapled haemorrhoidopexy and 388 to receive  traditional excisional surgery ) . Stapled haemorrhoidopexy was less painful  than traditional excisional surgery in the short term and surgical complication rates were similar between groups . The EQ-5D-3L AUC score was higher in the traditional excisional surgery group than the stapled haemorrhoidopexy group over 24 months ; mean difference −0·073 ( 95 % CI −0·140 to −0·006 ; p=0·0342 ) . EQ-5D-3L was higher for stapled haemorrhoidopexy in the first 6 weeks after surgery , the traditional excisional surgery group had significantly better quality of life scores than the stapled haemorrhoidopexy group . 24 ( 7 % ) of 338 participants who received stapled haemorrhoidopexy and 33 ( 9 % ) of 352 participants who received traditional excisional surgery  had serious adverse events . Interpretation As part of a tailored management plan for haemorrhoids , traditional excisional surgery should be considered over stapled haemorrhoidopexy as the surgical treatment of choice . Funding National Institute for Health Research Health Technology Assessment programme PURPOSE : Fissure-in-ano is characterized by pain , bleeding , and internal anal sphincter hypertonicity . Spasm of the internal sphincter also plays a role in hemorrhoidal disease and may be a source of anal pain after hemorrhoid surgery . Inducing sphincter relaxation with a nitroglycerin ointment has shown promise in healing anal fissures and relieving symptoms of pain . Our study attempts to test the hypothesis that topical nitroglycerin applied to the perianal region is beneficial in reducing pain after hemorrhoidectomy . METHODS : After hemorrhoidectomy 39 patients were r and omly assigned to receive 0.2 percent nitroglycerin ointment ( n=19 ) or placebo ( n=20 ) . Ointments were applied to the perianal region three times daily for seven days . Patients were prescribed hydrocodone bitartrate to take as needed . Visual analog scales were used to measure postoperative pain intensity and ointment benefits . Patients completed question naires to record medication morbidity and number of prescribed or nonprescribed medications taken . RESULTS : Patients using nitroglycerin had less pain and greater benefit from ointment than those did in the placebo group , but differences were not significant . Narcotic use was higher in the placebo group when considered on a daily basis , but was statistically significant on the second postoperative day only ( P<0.05 ) . Morbidity from ointment application was significantly higher in the nitroglycerin group ( P<0.002 ) and included a headache in 8 of 19 patients . Nonsteroidal anti-inflammatory drugs and acetaminophen were not prescribed , but were taken more frequently in nitroglycerin patients ( P<0.0003 ) . CONCLUSION : Perianal application of 0.2 percent nitroglycerin ointment after hemorrhoidectomy significantly reduced narcotic requirements on the second postoperative day . Headaches and a subsequent need for nonnarcotic medications may limit benefits of nitroglycerin INTRODUCTION Hemorrhoidal disease occurs in 50 % of people aged > 40 years and is the most common reason for anorectal surgery .  Pain is the main complication . Multiple topical and systemic drugs have been investigated for pain control , but there is no ideal treatment . Metronidazole has been shown to decrease postoperative pain but is not used widely . OBJECTIVE To evaluate the effect of oral metronidazole versus placebo and to assess postoperative pain following hemorrhoidectomy . MATERIAL AND METHODS Controlled clinical trial in adult patients who underwent elective hemorrhoidectomy for grade III/IV hemorrhoids . Patients were assigned to receive metronidazole ( 500 mg q8 h orally ; study group , SG ) or placebo ( control group , CG ) for 7 days after surgery . Pain was assessed using a visual analog scale after surgery . Analgesic administration ( time and use of analgesics ) and resumption of daily life activities were also assessed . RESULTS Forty-four patients were included , 22 in each group . Postoperative pain differed significantly between the SG and CG at 6 h ( 3.86 ± 0.56 , 6.64 ± 1.49 ) , 12 h ( 5.59 ± 1.33 , 8.82 ± 0.79 ) , 24 h ( 6.86 ± 1.49 , 9.73 ± 0.45 ) , day 4 ( 5.32 ± 2.10 , 9.50 ± 0.59 ) , day 7 ( 3.14 ± 1.03 , 7.36 ± 1.39 ) , and day 14 ( 2.14 ± 0.46 , 5.45 ± 1.29 ) . The first analgesia dose was required at 21.27 ± 5.47 h in the CG and 7.09 ± 2.36 h in the SG ( p < 0.05 ) , the time of analgesic use was 6.86 ± 1.61 days in the CG and 13.09 ± 2.48 days in the SG ( p < 0.05 ) , and resumption of daily activities occurred at 7.59 ± 1.56 days in the CG and 14.73 ± 3.76 days in the SG ( p < 0.05 ) . CONCLUSION Oral administration of metronidazole is effective in pain management after hemorrhoidectomy The effect of four days of preoperative lactulose on  posthaemorrhoidectomy pain  was studied in a prospect i ve double blind r and omized trial . All patients received lactulose on admission to hospital , 20 received lactulose for four days before admission , and 22 received placebo .  The preoperative lactulose treatment group suffered significantly less pain on defecation for the first four days that they opened their bowels ( visual analogue scores in cm : day 1 , 4.4 v 5.9 ; day 2 , 4.1 v 6.3 ; day 3 , 4.5 v 6.1 ; day 4 , 4.6 v 6.5 ) , suffered significantly less pain during the first two 24 hour periods after defecation ( visual analogue scores in cm : day 1 , 5.0 v 7.0 ; day 2 , 3.9 v 6.1 ) , and required significantly less analgesia daily after defecation ( 0.76 g paracetamol/day v 1.29 g paracetamol/day ) . These results show that lactulose given for four days preoperatively reduces pain after haemorrhoidectomy Summary Background Optimum surgical intervention for low- grade haemorrhoids is unknown . Haemorrhoidal artery ligation ( HAL ) has been proposed as an efficacious , safe therapy while rubber b and ligation ( RBL ) is a commonly used outpatient treatment . We compared recurrence after HAL versus RBL in patients with grade II – III haemorrhoids . Methods This multicentre , open-label , parallel group , r and omised controlled trial included patients from 17 acute UK NHS trusts . We screened patients aged 18 years or older presenting with grade II – III haemorrhoids . We excluded patients who had previously received any haemorrhoid surgery , more than one injection treatment for haemorrhoids , or more than one RBL procedure within 3 years before recruitment . Eligible patients were r and omly assigned ( in a 1:1 ratio ) to either RBL or HAL with Doppler . R and omisation was computer-generated and stratified by centre with blocks of r and om sizes . Allocation concealment was achieved using a web-based system . The study was open-label with no masking of participants , clinicians , or research staff . The primary outcome was recurrence at 1 year , derived from the patient 's self-reported assessment in combination with re source use from their general practitioner and hospital records . Recurrence was analysed in patients who had undergone one of the interventions and been followed up for at least 1 year . This study is registered with the IS RCT N registry , IS RCT N41394716 . Findings From Sept 9 , 2012 , to May 6 , 2014 , of 969 patients screened , 185 were r and omly assigned to the HAL group and 187 to the RBL group . Of these participants , 337 had primary outcome data ( 176 in the RBL group and 161 in the HAL group ) . At 1 year post-procedure , 87 ( 49 % ) of 176 patients in the RBL group and 48 ( 30 % ) of 161 patients in the HAL group had haemorrhoid recurrence ( adjusted odds ratio [ aOR ] 2·23 , 95 % CI 1·42–3·51 ; p=0·0005 ) . The main reason for this difference was the number of extra procedures required to achieve improvement ( 57 [ 32 % ] participants in the RBL group and 23 [ 14 % ] participants in the HAL group had a subsequent procedure for haemorrhoids ) . The mean pain 1 day after procedure was 3·4 ( SD 2·8 ) in the RBL group and 4·6 ( 2·8 ) in the HAL group ( difference −1·2 , 95 % CI −1·8 to −0·5 ; p=0·0002 ) ; at day 7 the scores were 1·6 ( 2·3 ) in the RBL group and 3·1 ( 2·4 ) in the HAL group ( difference −1·5 , −2·0 to −1·0 ; p<0·0001 ) . Pain scores did not differ between groups at 21 days and 6 weeks . 15 individuals reported serious adverse events requiring hospital admission . One patient in the RBL group had a pre-existing rectal tumour . Of the remaining 14 serious adverse events 
    Output:
    
CONCLUSION Metronidazole is a cheap , safe and effective intervention for reducing postoperative pain following conventional haemorrhoidectomy