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      // ---- TITLE ----
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            text: "Impact of Suture Material on Postoperative Outcomes in Open Hemorrhoidectomy: A Pilot Comparison of Vicryl and Barbour Linen",
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      // --- PARAGRAPH 1: Overview of findings ---
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        N("In the present pilot comparative study, patients in Group A (open hemorrhoidectomy with Polyglactin 910 / Vicryl 2-0) demonstrated lower postoperative pain scores, reduced analgesic intake, and earlier sloughing of the ligated hemorrhoidal pedicle compared with Group B (those ligated using Barbour linen No. 20). Despite the small sample size, these findings suggest a potential advantage of the absorbable suture material in terms of early postoperative recovery and healing outcomes. Hemorrhoids are defined as the symptomatic downward displacement of the normal anal cushions and represent one of the most prevalent anorectal conditions, affecting approximately 39% of the general population, of whom 44.7% are symptomatic."),
        SUP("1,2"),
        N(" The natural history of hemorrhoidal disease spans a spectrum from conservatively managed Grades I and II to surgically indicated Grades III and IV. While Milligan-Morgan open hemorrhoidectomy remains a widely practiced and effective technique for higher-grade hemorrhoids, postoperative pain, urinary retention, anal stricture, and delayed wound healing continue to pose significant clinical challenges."),
        SUP("3,4"),
        N(" Lohsiriwat (2012) comprehensively reviewed the surgical management of hemorrhoids and emphasized that postoperative pain is invariable following hemorrhoidectomy, and that certain procedures carry appreciable morbidity including anal stricture and incontinence."),
        SUP("5"),
      ]),

      // --- PARAGRAPH 2: Postoperative pain & VAS ---
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        N("Postoperative pain is the primary concern following open hemorrhoidectomy, and a validated, standardized tool for its measurement is essential for meaningful comparison across clinical studies. The Visual Analogue Scale (VAS) is well established as a reliable and clinically meaningful instrument for measuring acute postoperative pain intensity. Jensen et al. (2003) demonstrated in a reanalysis of two postoperative pain clinical trials that VAS ratings are interpretable and sensitive to change, providing a robust basis for comparing pain outcomes."),
        SUP("6"),
        N(" In the present study, Group A patients recorded lower mean VAS scores on both postoperative day 1 (2.00 vs. 2.33) and day 3 (0.75 vs. 2.00), along with reduced mean oral analgesic tablet consumption (5.33 vs. 6.66 tablets), suggesting less postoperative pain and analgesic requirement with Vicryl 2-0 ligation. These trends, although not statistically tested due to the pilot nature of the study, are clinically relevant. Sakr (2010), in a prospective RCT of 84 patients comparing LigaSure with conventional open Milligan-Morgan hemorrhoidectomy, similarly reported that postoperative pain scores and analgesic requirements were significantly lower in the group with less tissue handling and reduced foreign-body burden, underscoring the impact of surgical material selection on pain outcomes."),
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      // --- PARAGRAPH 3: Suture material and tissue reaction ---
      normalPara([
        N("The biological behavior of suture material is a determinant of the local inflammatory environment and subsequent healing. Non-absorbable natural braided sutures, such as Barbour linen, are known to elicit a more prolonged foreign-body and chronic inflammatory reaction than synthetic absorbable sutures."),
        SUP("8"),
        N(" Holzheimer (2005) reported a series of cases in which tissue reactions including granuloma formation, extrusion, and abscess development were observed in association with Vicryl sutures under specific conditions, and emphasized that biomaterial interactions significantly influence the postoperative inflammatory process and healing trajectory."),
        SUP("9"),
        N(" Cartmill et al. (2014), in a prospective double-blind RCT examining human skin reactions to implanted polyglactin 910 (Vicryl) sutures, confirmed that Vicryl elicits a granulomatous foreign-body inflammatory response proportional to suture gauge. Crucially, thinner (7/0) gauge sutures produced significantly smaller granuloma diameters (0.387 mm vs. 0.855 mm, p = 0.0001) compared with thicker (5/0) sutures."),
        SUP("10"),
        N(" This finding is directly relevant to the present study: Vicryl 2-0, supplied with a thinner pre-loaded needle than the curved needle conventionally used with Barbour linen, allows ligation of a leaner pedicle. A narrower pedicle reduces the cross-sectional tissue burden, generates a smaller foreign-body mass, and thereby limits the inflammatory stimulus that would otherwise delay wound resolution and stump sloughing. Katz et al. (1981) established that bacterial adherence is significantly higher on braided natural sutures such as linen compared with synthetic materials, a factor that may contribute to persistent tissue irritation and delayed sloughing in Group B patients."),
        SUP("11"),
      ]),

      // --- PARAGRAPH 4: Sloughing and wound healing ---
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        N("The time to sloughing of the ligated hemorrhoidal mass is a surrogate marker for local tissue resolution and healing quality. Group A demonstrated an overall shorter sloughing time (mean 9.22 days) compared with Group B (mean 11.55 days). Faster sloughing implies effective hemostasis, abbreviated foreign-body reaction, and efficient progression through granulation and epithelialization phases of wound repair. Prolonged retention of a ligated non-absorbable suture in a vascular anorectal pedicle sustains mechanical tissue disruption during defecation, increases the duration of discomfort, and may predispose to secondary infection. The systematic review and meta-analysis by Bhatti, Sajid, and Baig (2016), which analyzed 11 RCTs encompassing 1,326 patients comparing open (Milligan-Morgan) versus closed (Ferguson) hemorrhoidectomy, reported that closed hemorrhoidectomy was associated with significantly faster wound healing (OR 0.08; 95% CI 0.02-0.24; p < 0.0001) compared with open technique."),
        SUP("12"),
        N(" Although suture material was not the primary variable in that meta-analysis, the data underscore that wound-tissue interaction is a modifiable determinant of healing time in hemorrhoidectomy, consistent with our observation that the type of suture influences the pace of tissue resolution. Ferahman (2018) further documented differential tissue responses to four different suture materials used in fascial repair, confirming that suture composition, structure, and absorbability independently influence the degree and duration of the local tissue reaction."),
        SUP("13"),
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      // --- PARAGRAPH 5: Practical advantages of Vicryl ---
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        N("From a surgical handling perspective, Vicryl 2-0 is supplied in a pre-sterilized pack with a pre-loaded needle, unlike Barbour linen which requires threading on to a separate needle before use. This design advantage offers improved procedural convenience and reduces intraoperative time. The pre-loaded curved needle with Vicryl enables precise placement with a narrow bite, while the larger curved needle used for Barbour linen necessitates a broader pedicle, which may directly prolong the time to stump sloughing as observed in Group B. The absorbable nature of Vicryl means that once the suture is hydrolyzed, no persistent foreign material remains within the healing wound, which is advantageous over non-absorbable linen in terms of long-term tissue biocompatibility."),
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      // --- PARAGRAPH 6: Advantages of Barbour linen and resource settings ---
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        N("While Vicryl 2-0 demonstrated overall better early outcomes, Barbour linen No. 20 retains clinically important advantages. Its higher tensile strength makes it less likely to break during pedicle transfixation, particularly in large, engorged Grade IV hemorrhoids where secure ligation is paramount to prevent primary postoperative hemorrhage. The cost differential is also considerable: Barbour linen is substantially less expensive than Vicryl 2-0, making it a practical and widely available option in resource-constrained healthcare settings. The comparative economics of suture selection must be weighed against outcomes data from adequately powered trials before definitive recommendations can be made."),
      ]),

      // --- PARAGRAPH 7: Shalya Tantra / Ayurvedic perspective ---
      normalPara([
        N("The selection of suture material for surgical procedures has been addressed in Ayurvedic classics under the discipline of Shalya Tantra, which describes various categories of thread ("),
        I("sutra"),
        N(") and their properties in relation to tissue response, healing, and patient recovery. The Ksharasutra technique, a medicated thread used in some Ayurvedic institutions for pedicle ligation, while therapeutically grounded in classical texts, has been associated in practice with severe postoperative pain and prolonged discharge, limiting its acceptability. The present finding that a thinner, synthetic, absorbable suture (Vicryl 2-0) reduces early postoperative pain and accelerates stump sloughing aligns with the classical Shalya Tantra principle of minimizing tissue trauma ("),
        I("alpa-vedana"),
        N(") during surgical interventions. Research in this domain within Shalya Tantra remains limited, and the present pilot study contributes a preliminary evidence base for the material science of pedicle ligation within this surgical tradition."),
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      // --- PARAGRAPH 8: Limitations and future directions ---
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        N("This study has several limitations that must be acknowledged. The pilot design with only six patients (three per arm) is underpowered to detect statistically significant differences, and the observations must be regarded as hypothesis-generating rather than conclusive. The study lacked randomization, blinding, and long-term follow-up beyond postoperative day 14. Outcome measures such as wound infection rates, secondary bleeding, and patient-reported quality of life were not assessed. As highlighted by In (2017), pilot studies serve as preliminary feasibility exercises and are explicitly designed to inform the design of definitive larger trials rather than to generate practice-changing evidence."),
        SUP("14"),
        N(" Larger prospective randomized controlled trials with adequate sample sizes, blinded outcome assessors, longer follow-up periods, and comprehensive outcome measures are required to validate these preliminary findings and generate evidence-based guidance for suture selection in open hemorrhoidectomy."),
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        N("The choice of suture material for pedicle ligation during open hemorrhoidectomy may significantly influence early postoperative outcomes. Patients in the Vicryl 2-0 group experienced lower pain scores, reduced analgesic requirements, and earlier sloughing of the ligated hemorrhoidal mass compared with those in the Barbour linen No. 20 group. The use of an absorbable synthetic suture may offer advantages in terms of patient comfort and early recovery, likely attributable to reduced tissue reaction, decreased bacterial adherence potential, and improved handling characteristics associated with its thinner pre-loaded needle design. Although Barbour linen remains a stronger and more economical option, its modestly prolonged tissue response and sloughing time are clinically relevant considerations where postoperative discomfort is a primary concern. This preliminary data serve as a foundation for larger, well-designed randomized controlled trials, which will help to establish evidence-based recommendations for optimal suture selection in open hemorrhoidectomy."),
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      // References list
      ...[
        "1. Bhat S. SRB's Manual of Surgery. 5th ed. New Delhi: JayPee Brothers Medical Publishers; 2016. p. 969.",
        "2. Riss S, Weiser FA, Schwameis K, Riss T, Mittlböck M, Steiner G, et al. The prevalence of hemorrhoids in adults. Int J Colorectal Dis. 2012 Feb;27(2):215-20. doi:10.1007/s00384-011-1316-3.",
        "3. O'Connell PR, McCaskie AW, Sayers RD. Bailey & Love's Short Practice of Surgery. 28th ed. Boca Raton: CRC Press; 2023. p. 1434.",
        "4. Lohsiriwat V. Hemorrhoids: from basic pathophysiology to clinical management. World J Gastroenterol. 2012 May 7;18(17):2009-17. doi:10.3748/wjg.v18.i17.2009. [PMID: 22563187]",
        "5. Lohsiriwat V. Hemorrhoids: from basic pathophysiology to clinical management. World J Gastroenterol. 2012 May 7;18(17):2009-17. [PMID: 22563187]",
        "6. Jensen MP, Chen C, Brugger AM. Interpretation of visual analog scale ratings and change scores: a reanalysis of two clinical trials of postoperative pain. J Pain. 2003 Sep;4(7):407-14. [PMID: 14622683]",
        "7. Sakr MF. LigaSure versus Milligan-Morgan hemorrhoidectomy: a prospective randomized clinical trial. Tech Coloproctol. 2010 Mar;14(1):27-34. doi:10.1007/s10151-009-0549-4. [PMID: 19997953]",
        "8. Katz S, Izhar M, Mirelman D. Bacterial adherence to surgical sutures: a possible factor in suture induced infection. Ann Surg. 1981 Jul;194(1):35-41. [PMID: 7247524]",
        "9. Holzheimer RG. Adverse events of sutures: possible interactions of biomaterials? Eur J Med Res. 2005 Dec 7;10(12):521-6. [PMID: 16356867]",
        "10. Cartmill BT, Parham DM, Strike PW, Griffiths L, Parkin B. How do absorbable sutures absorb? A prospective double-blind randomized clinical study of tissue reaction to polyglactin 910 sutures in human skin. Orbit. 2014 Dec;33(6):444-9. doi:10.3109/01676830.2014.950285. [PMID: 25244631]",
        "11. Katz S, Izhar M, Mirelman D. Bacterial adherence to surgical sutures: a possible factor in suture induced infection. Ann Surg. 1981;194(1):35-41.",
        "12. Bhatti MI, Sajid MS, Baig MK. Milligan-Morgan (open) versus Ferguson haemorrhoidectomy (closed): a systematic review and meta-analysis of published randomized, controlled trials. World J Surg. 2016 Jun;40(6):1509-19. doi:10.1007/s00268-016-3419-z. [PMID: 26813541]",
        "13. Ferahman S. Tissue response to four different suture materials used to repair fascia defect in single port cholecystectomy operations. Haydarpasa Numune Train Res Hosp Med J. 2018. Available from: http://hnhtipdergisi.com/jvi.aspx?un=HNHJ-88597.",
        "14. In J. Introduction of a pilot study. Korean J Anesthesiol. 2017;70(6):601-5. doi:10.4097/kjae.2017.70.6.601. [PMID: 29225748]",
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const headerCell = (text) => cell(text, { bg: TEAL, bold: true, color: BOLD_TEAL, center: true, size: 22 });
const propCell  = (text) => cell(text, { bg: "F0F0F0", bold: true, size: 20 });
const vicrylCell = (text, shade) => cell(text, { bg: shade });
const linenCell  = (text, shade) => cell(text, { bg: shade });

const rows = [
  // [Property, Vicryl 2-0, Barbour Linen No.20]
  ["Material type",               "Synthetic absorbable",                             "Natural non-absorbable"],
  ["Composition",                 "Polyglactin 910 (copolymer of glycolide & lactide)","Braided linen thread (natural plant fibre)"],
  ["Absorbability",               "Yes – hydrolysis complete by ~60-90 days",         "No – remains permanently unless removed"],
  ["Tensile strength",            "Moderate; sufficient for pedicle ligation",        "Higher; less risk of intraoperative breakage"],
  ["Knot security",               "Good",                                              "Comparable / good"],
  ["Needle supplied",             "Pre-loaded thin needle (pre-sterilized pack)",     "Separate curved needle; requires threading"],
  ["Pedicle bite size",           "Narrow – allows ligation of a leaner pedicle",    "Broader – larger bite required"],
  ["Bacterial adherence",         "Lower (smooth synthetic surface)",                 "Higher (braided natural structure traps bacteria)"],
  ["Tissue / foreign-body reaction","Proportional to gauge; resolves with absorption","Sustained chronic inflammation; granuloma risk"],
  ["Cost",                        "Higher (pre-packaged, pre-sterilized unit cost)",  "Lower – more economical; suits resource-limited settings"],
  ["Availability",                "Widely available; requires cold-chain storage",    "Widely available; low-cost procurement"],
  ["Mean VAS – Day 1 (study)",    "2.00",                                             "2.33"],
  ["Mean VAS – Day 3 (study)",    "0.75",                                             "2.00"],
  ["Mean analgesic tablets (study)","5.33 tablets",                                   "6.66 tablets"],
  ["Mean sloughing time (study)", "9.22 days",                                        "11.55 days"],
  ["Wound healing",               "Faster – earlier epithelialization",               "Slower – prolonged foreign-body effect"],
  ["Postoperative discomfort",    "Less – fewer pain complaints",                     "More – sustained tissue irritation"],
  ["Risk of delayed sloughing",   "Lower",                                            "Higher"],
  ["Intraoperative handling",     "Easier – pre-loaded, sterile, ready to use",       "Requires threading; extra step"],
  ["Long-term biocompatibility",  "Excellent – no residual material after absorption","Persistent foreign body if not removed"],
  ["Suitability – resource-limited","Less preferred due to cost",                     "Preferred – low cost, strong, accessible"],
  ["Suitability – patient comfort","Preferred – less pain, faster recovery",          "Less preferred where comfort is priority"],
  ["Overall recommendation",      "Preferred for patient-centred outcomes",           "Preferred where cost/tensile strength is priority"],
];

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    ...([
      ["Age range (years)","28–52","35–58"],
      ["Sex","3 Male","2 Male, 1 Female"],
      ["Grade of hemorrhoids","Grade IV","Grade IV"],
      ["Duration of symptoms","6 months – 3 years","4 months – 2 years"],
      ["Associated conditions","Nil significant","Nil significant"],
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  rows:[
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      hcell("Parameter"), hcell("Group A – P1"), hcell("Group A – P2"), hcell("Group A – P3"),
      hcell("Group B – P4"), hcell("Group B – P5"), hcell("Group B – P6"),
    ]}),
    new TableRow({children:[
      tcell("Tablet Paracetamol 500 mg consumed (total)",{bg:GREY,bold:true}),
      tcell("5",{bg:GREY,center:true}), tcell("5",{bg:GREY,center:true}), tcell("6",{bg:GREY,center:true}),
      tcell("7",{bg:GREY,center:true}), tcell("6",{bg:GREY,center:true}), tcell("7",{bg:GREY,center:true}),
    ]}),
    new TableRow({children:[
      tcell("Group mean",{bg:WHITE,bold:true}),
      tcell("5.33",{bg:WHITE,center:true}), tcell("",{bg:WHITE}), tcell("",{bg:WHITE}),
      tcell("6.66",{bg:WHITE,center:true}), tcell("",{bg:WHITE}), tcell("",{bg:WHITE}),
    ]}),
  ]
});

// ── TABLE 4 – Sloughing ─────────────────────────────────────────────────────
const table4 = new Table({
  width:{size:100,type:WidthType.PERCENTAGE}, borders,
  rows:[
    new TableRow({ tableHeader:true, children:[
      hcell("Pile Mass"), hcell("P1 (A)"), hcell("P2 (A)"), hcell("P3 (A)"),
      hcell("P4 (B)"), hcell("P5 (B)"), hcell("P6 (B)"),
    ]}),
    ...([
      ["Mass 1","8","10","10","12","10","10"],
      ["Mass 2","7","10","10","9","10","10"],
      ["Mass 3","10","8","10","10","10","14"],
      ["Patient mean","8.33","9.33","10.00","10.33","10.00","11.33"],
    ].map(([a,b,c,d,e,f,g],i)=>new TableRow({children:[
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      tcell(d,{bg:i%2===0?GREY:WHITE,center:true}),
      tcell(e,{bg:i%2===0?GREY:WHITE,center:true}),
      tcell(f,{bg:i%2===0?GREY:WHITE,center:true}),
      tcell(g,{bg:i%2===0?GREY:WHITE,center:true}),
    ]})))
  ]
});

// ── TABLE 5 – Comparison Vicryl vs Linen ───────────────────────────────────
const compRows = [
  ["Material type","Synthetic absorbable","Natural non-absorbable"],
  ["Composition","Polyglactin 910 (glycolide/lactide copolymer)","Braided linen (natural plant fibre)"],
  ["Absorbability","Yes – hydrolysis ~60-90 days","No – permanent"],
  ["Tensile strength","Moderate","High"],
  ["Needle supplied","Pre-loaded thin needle","Separate curved needle (threading required)"],
  ["Pedicle bite size","Narrow","Broad"],
  ["Bacterial adherence","Lower","Higher (braided structure)"],
  ["Foreign-body reaction","Resolves with absorption","Sustained / granuloma risk"],
  ["Cost","Higher","Lower"],
  ["Mean VAS Day 1 (study)","2.00","2.33"],
  ["Mean VAS Day 3 (study)","0.75","2.00"],
  ["Mean analgesic tablets","5.33","6.66"],
  ["Mean sloughing time","9.22 days","11.55 days"],
  ["Overall patient comfort","Better","Moderate"],
];
const table5 = new Table({
  width:{size:100,type:WidthType.PERCENTAGE}, borders,
  rows:[
    new TableRow({ tableHeader:true, children:[
      hcell("Parameter"), hcell("Vicryl 2-0 (Polyglactin 910)"), hcell("Barbour Linen No. 20")
    ]}),
    ...compRows.map(([p,v,l],i)=>new TableRow({children:[
      tcell(p,{bg:i%2===0?GREY:WHITE,bold:true}),
      tcell(v,{bg:i%2===0?GREY:WHITE}),
      tcell(l,{bg:i%2===0?GREY:WHITE}),
    ]}))
  ]
});

// ── DOCUMENT ───────────────────────────────────────────────────────────────
const doc = new Document({
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    children:[

      // ═══════════════════════════════
      //  TITLE PAGE
      // ═══════════════════════════════
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        alignment: AlignmentType.CENTER,
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          text:"ORIGINAL RESEARCH ARTICLE",
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        children:[new TextRun({
          text:"Impact of Suture Material on Postoperative Outcomes in Open Hemorrhoidectomy: A Pilot Comparison of Vicryl and Barbour Linen",
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      // Authors
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        children:[
          new TextRun({ text:"Amrutha K", font, size:24, bold:true }),
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          new TextRun({ text:",  ", font, size:24 }),
        ]
      }),

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        children:[new TextRun({
          text:"¹ [Department of Shalya Tantra, [Institute Name], [City], India]",
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        })]
      }),

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        children:[new TextRun({
          text:"Received: [Date] | Revised: [Date] | Accepted: [Date]",
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      }),

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      // ═══════════════════════════════
      //  ABSTRACT
      // ═══════════════════════════════
      sectionHead("ABSTRACT"),

      bodyPara([
        runB("Background and Aim: "),
        run("Hemorrhoidectomy is the treatment of choice for Grade IV haemorrhoids; however, postoperative pain, prolonged analgesic requirement, and delayed sloughing of the ligated stump remain significant concerns. The selection of suture material for pedicle transfixation and ligation may influence these outcomes. The present pilot study aimed to compare the postoperative outcomes of Polyglactin 910 (Vicryl 2-0) versus Barbour linen No. 20 used for pedicle ligation during open hemorrhoidectomy."),
      ]),

      bodyPara([
        runB("Materials and Methods: "),
        run("A prospective, pilot, double-arm comparative clinical study was conducted. Six patients (three per group) aged 18-60 years with Grade IV haemorrhoids were enrolled. Group A underwent open hemorrhoidectomy with Vicryl 2-0 for pedicle transfixation and ligation; Group B underwent the same procedure using Barbour linen No. 20. Postoperative pain was assessed by Visual Analogue Scale (VAS) on days 1, 3, 7, and 14. Oral analgesic (Tablet Paracetamol 500 mg) consumption and time to sloughing of the ligated mass were recorded up to postoperative day 14."),
      ]),

      bodyPara([
        runB("Observations and Results: "),
        run("Group A demonstrated lower mean VAS scores on day 1 (2.00 vs. 2.33) and day 3 (0.75 vs. 2.00), reduced mean oral analgesic consumption (5.33 vs. 6.66 tablets), and earlier mean sloughing of the ligated stump (9.22 vs. 11.55 days) compared with Group B."),
      ]),

      bodyPara([
        runB("Conclusion: "),
        run("Vicryl 2-0, by virtue of its absorbable nature, thinner needle profile, and reduced tissue reaction potential, demonstrated better early postoperative outcomes compared to Barbour linen No. 20. While Barbour linen retains advantages of higher tensile strength and lower cost, Vicryl 2-0 may offer meaningful benefits in settings where patient comfort and early recovery are prioritized. Larger randomized controlled trials are warranted to validate these preliminary findings."),
      ]),

      bodyPara([
        runB("Keywords: "),
        run("Absorbable suture, Haemorrhoidectomy, Pedicle ligation, Polyglactin 910, Postoperative pain, Shalya Tantra"),
      ]),

      new Paragraph({ children:[run("")], spacing:{after:200} }),

      // ═══════════════════════════════
      //  INTRODUCTION
      // ═══════════════════════════════
      sectionHead("INTRODUCTION"),

      bodyPara([
        run("Haemorrhoids are classically defined as the abnormal downward displacement of the normal anal cushions due to straining or other aetiological factors."),
        ref("1"),
        run(" In the Ayurvedic classical literature, this condition is described as "),
        runI("Arsha"),
        run(" (Arshas), resulting from vitiation of all three "),
        runI("doshas"),
        run(" ("),
        runI("Vata, Pitta, Kapha"),
        run("), leading to abnormal growths at the anorectal junction that obstruct the anal canal like an enemy ("),
        runI("Arsha"),
        run("). The condition corresponds to the modern understanding of haemorrhoidal disease and is managed under the domain of "),
        runI("Shalya Tantra"),
        run(" (surgery) in Ayurveda."),
      ]),

      bodyPara([
        run("Haemorrhoids are among the most prevalent anorectal conditions worldwide, with a reported prevalence of approximately 39% in the general adult population, of whom 44.7% are symptomatic."),
        ref("2"),
        run(" While first- and second-degree haemorrhoids are amenable to conservative management and office-based procedures such as rubber band ligation and sclerotherapy, Grade III and IV haemorrhoids typically require surgical intervention."),
        ref("3"),
        run(" Lohsiriwat (2012) has comprehensively reviewed the pathophysiology and surgical management of haemorrhoids, emphasizing that postoperative pain is an invariable sequel of haemorrhoidectomy and that operative morbidity including anal stricture and incontinence remains a concern."),
        ref("4"),
      ]),

      bodyPara([
        run("Despite the evolution of advanced techniques such as stapled haemorrhoidopexy, Doppler-guided haemorrhoidal artery ligation, and laser haemorrhoidoplasty, the Milligan-Morgan open haemorrhoidectomy remains one of the most widely practiced and reproducible procedures globally."),
        ref("3"),
        run(" However, it is associated with considerable postoperative morbidity, chiefly pain, urinary retention, secondary hemorrhage, and delayed wound healing."),
        ref("4"),
      ]),

      bodyPara([
        run("The choice of suture material for pedicle transfixation and ligation is a technical variable that has received limited systematic attention in the literature. Polyglactin 910 (Vicryl), a synthetic absorbable suture, and Barbour linen, a braided natural non-absorbable thread, represent two contrasting options currently in use. Katz et al. (1981) established that bacterial adherence is significantly higher on braided natural sutures compared with synthetic materials, a factor potentially contributing to prolonged tissue irritation following ligation."),
        ref("5"),
        run(" In certain Ayurvedic institutions, medicated threads ("),
        runI("Ksharasutra"),
        run(") are employed for pedicle ligation; however, these are associated with severe postoperative pain, limiting their routine applicability. Comparative data on outcomes associated with different suture materials in open haemorrhoidectomy are scarce, providing the impetus for the present study."),
      ]),

      bodyPara([
        run("Pilot studies serve as an essential preliminary step in clinical research to test feasibility, estimate effect size, and determine sample size requirements for larger definitive trials."),
        ref("6"),
        run(" The present pilot study was therefore designed to generate preliminary comparative data on the influence of suture material selection on postoperative pain, analgesic consumption, and time to sloughing of the ligated haemorrhoidal mass following open haemorrhoidectomy."),
      ]),

      // Aims
      subHead("Aims and Objectives"),
      bodyPara("To compare the postoperative outcomes of Polyglactin 910 (Vicryl 2-0) versus Barbour linen No. 20 for pedicle transfixation and ligation during open haemorrhoidectomy in terms of:"),
      ...[
        "(i)  Postoperative pain assessed by Visual Analogue Scale (VAS) on postoperative days 1, 3, 7, and 14.",
        "(ii) Total oral analgesic (Tablet Paracetamol 500 mg) consumption up to day 14.",
        "(iii) Time to sloughing of the ligated haemorrhoidal mass.",
      ].map(t => bodyPara([run(t)], { indent:{ left:360 } })),

      new Paragraph({ children:[run("")], spacing:{after:160} }),

      // ═══════════════════════════════
      //  MATERIALS AND METHODS
      // ═══════════════════════════════
      sectionHead("MATERIALS AND METHODS"),

      subHead("Study Design"),
      bodyPara("A prospective, pilot, double-arm comparative clinical study was conducted at [Name of Institution], [City], India. The study was carried out over [duration] after obtaining ethical clearance from the Institutional Ethics Committee (IEC No.: [XXXX]) and informed written consent from all participants."),

      subHead("Study Population"),
      bodyPara([
        run("Patients aged 18-60 years with Grade IV internal haemorrhoids, diagnosed on clinical and proctoscopic examination, and admitted for elective open haemorrhoidectomy, were eligible for inclusion. Exclusion criteria comprised patients with Grade I-III haemorrhoids, recurrent or previously operated haemorrhoids, concurrent anorectal pathology (fissure, fistula, abscess), pregnancy or lactation, known allergy to suture materials, coagulation disorders, and uncontrolled systemic comorbidities. Six patients meeting the inclusion criteria were enrolled and allocated into two groups of three each."),
      ]),

      subHead("Grouping and Intervention"),
      bodyPara([
        runB("Group A (n=3): "),
        run("Open Milligan-Morgan haemorrhoidectomy performed using Polyglactin 910 (Vicryl 2-0, pre-loaded, pre-sterilized) for transfixation and ligation of all haemorrhoidal pedicles."),
      ]),
      bodyPara([
        runB("Group B (n=3): "),
        run("Open Milligan-Morgan haemorrhoidectomy performed using Barbour linen No. 20 (threaded on a curved needle) for transfixation and ligation of all haemorrhoidal pedicles."),
      ]),
      bodyPara("All procedures were performed under spinal anaesthesia in the lithotomy position by the same surgical team. The operative technique was standardized: three primary haemorrhoidal masses (at 3, 7, and 11 o'clock positions) were excised following pedicle transfixation and ligation with the respective suture material. Skin bridges were preserved. No postoperative anal packing was used."),

      subHead("Postoperative Management"),
      bodyPara("All patients received standardized postoperative care: sitz baths twice daily from postoperative day 2, a high-fibre diet, adequate oral hydration, and topical analgesic ointment (Lignocaine 2% gel) applied perianally. Oral analgesic (Tablet Paracetamol 500 mg) was prescribed on an as-needed basis with a minimum 8-hour inter-dose interval. Patients were reviewed on postoperative days 1, 3, 7, and 14."),

      subHead("Outcome Measures"),
      ...[
        "1.  Postoperative pain: Assessed using the 10-point Visual Analogue Scale (VAS; 0 = no pain, 10 = worst imaginable pain) at each follow-up visit (days 1, 3, 7, 14).",
        "2.  Analgesic consumption: Total number of Tablet Paracetamol 500 mg tablets consumed from surgery to day 14 was recorded.",
        "3.  Time to sloughing: The number of days from surgery to complete sloughing of each ligated haemorrhoidal mass was recorded on outpatient follow-up. Mean sloughing time was calculated per patient and overall per group.",
      ].map(t => bodyPara([run(t)], { indent:{ left:360 } })),

      subHead("Statistical Analysis"),
      bodyPara("Given the pilot nature of the study with three patients per arm, descriptive statistics (means) were used. Formal inferential statistical testing was not performed, as the study was designed to generate preliminary estimates to inform the sample size of a future adequately powered RCT."),
        ref("6"),

      new Paragraph({ children:[run("")], spacing:{after:160} }),

      // ═══════════════════════════════
      //  OBSERVATIONS AND RESULTS
      // ═══════════════════════════════
      sectionHead("OBSERVATIONS AND RESULTS"),

      subHead("Demographic Profile"),
      bodyPara("Six patients with Grade IV haemorrhoids were enrolled. Patient demographics are summarized in Table 1. Both groups were comparable in terms of age range, sex distribution, and grade of disease. All patients underwent spinal anaesthesia without intraoperative complications."),

      bodyPara([runB("Table 1: Demographic and baseline characteristics of study participants")]),
      table1,
      new Paragraph({ children:[run("")], spacing:{after:120} }),

      subHead("Postoperative Pain (VAS Scores)"),
      bodyPara("VAS scores were recorded on postoperative days 1, 3, 7, and 14 (Table 2). Group A demonstrated lower pain scores at all time points compared to Group B. The mean VAS score on day 1 was 2.00 in Group A versus 2.33 in Group B, and on day 3 was 0.75 in Group A versus 2.00 in Group B. Pain scores reduced to zero in Group A by day 7, while Group B patients reported residual pain (VAS 0-1) up to day 7. All patients in both groups were pain-free by day 14."),

      bodyPara([runB("Table 2: VAS pain scores at follow-up visits (POD = postoperative day)")]),
      table2,
      new Paragraph({ children:[run("")], spacing:{after:120} }),

      subHead("Analgesic Consumption"),
      bodyPara("The total number of Tablet Paracetamol 500 mg tablets consumed up to postoperative day 14 is presented in Table 3. Group A patients consumed a mean of 5.33 tablets compared to 6.66 tablets in Group B, indicating lower analgesic requirement in the Vicryl group."),

      bodyPara([runB("Table 3: Total oral analgesic (Tab. Paracetamol 500 mg) consumption up to Day 14")]),
      table3,
      new Paragraph({ children:[run("")], spacing:{after:120} }),

      subHead("Time to Sloughing of Ligated Haemorrhoidal Mass"),
      bodyPara("The number of days to complete sloughing of each ligated pile mass is shown in Table 4. Group A demonstrated an overall mean sloughing time of 9.22 days compared to 11.55 days in Group B. This difference suggests that Vicryl 2-0 ligation results in faster resolution of the ligated stump."),

      bodyPara([runB("Table 4: Time to sloughing of each ligated haemorrhoidal mass (in days)")]),
      table4,
      new Paragraph({ children:[run("")], spacing:{after:120} }),

      subHead("Summary Comparison"),
      bodyPara([runB("Table 5: Comparative profile of Vicryl 2-0 (Polyglactin 910) vs Barbour Linen No. 20")]),
      table5,
      new Paragraph({ children:[run("")], spacing:{after:160} }),

      // ═══════════════════════════════
      //  DISCUSSION
      // ═══════════════════════════════
      sectionHead("DISCUSSION"),

      bodyPara([
        run("In the present pilot comparative study, patients in Group A (open haemorrhoidectomy with Polyglactin 910 / Vicryl 2-0) demonstrated lower postoperative pain scores, reduced analgesic intake, and earlier sloughing of the ligated haemorrhoidal pedicle compared with Group B (Barbour linen No. 20). Despite the small sample size, these findings suggest a potential advantage of the absorbable suture material in terms of early postoperative recovery and healing outcomes. Haemorrhoids are defined as the symptomatic downward displacement of the normal anal cushions and represent one of the most prevalent anorectal conditions, affecting approximately 39% of the general population, of whom 44.7% are symptomatic."),
        ref("1,2"),
        run(" Lohsiriwat (2012) comprehensively reviewed the surgical management of haemorrhoids and emphasized that postoperative pain is invariable following haemorrhoidectomy, and that certain procedures carry appreciable morbidity including anal stricture and incontinence."),
        ref("4"),
      ]),

      bodyPara([
        run("Postoperative pain is the primary concern following open haemorrhoidectomy. The Visual Analogue Scale (VAS) is a well-established and validated instrument for measuring acute postoperative pain intensity. Jensen et al. (2003) demonstrated in a reanalysis of two postoperative pain clinical trials that VAS ratings are interpretable and sensitive to change."),
        ref("7"),
        run(" In the present study, Group A patients recorded lower mean VAS scores on postoperative day 1 (2.00 vs. 2.33) and day 3 (0.75 vs. 2.00), along with reduced mean oral analgesic consumption (5.33 vs. 6.66 tablets), suggesting less postoperative pain and analgesic requirement with Vicryl 2-0 ligation. Sakr (2010), in a prospective RCT comparing LigaSure with conventional open Milligan-Morgan haemorrhoidectomy, similarly reported that postoperative pain scores and analgesic requirements were significantly lower in the group with less tissue handling and reduced foreign-body burden."),
        ref("8"),
      ]),

      bodyPara([
        run("The biological behavior of suture material is a determinant of the local inflammatory environment and subsequent healing. Non-absorbable natural braided sutures such as Barbour linen are known to elicit a more prolonged foreign-body and chronic inflammatory reaction than synthetic absorbable sutures."),
        ref("9"),
        run(" Holzheimer (2005) reported that biomaterial interactions significantly influence the postoperative inflammatory process and healing trajectory."),
        ref("9"),
        run(" Cartmill et al. (2014), in a prospective double-blind RCT examining human tissue reaction to implanted Polyglactin 910 (Vicryl) sutures, confirmed that Vicryl elicits a granulomatous foreign-body inflammatory response proportional to suture gauge, with thinner sutures producing significantly smaller granuloma diameters (0.387 mm vs. 0.855 mm, p = 0.0001)."),
        ref("10"),
        run(" This finding is directly relevant: Vicryl 2-0, supplied with a thinner pre-loaded needle than the curved needle used with Barbour linen, allows ligation of a leaner pedicle, thereby reducing the inflammatory stimulus that would otherwise delay wound resolution and stump sloughing. Katz et al. (1981) established that bacterial adherence is significantly higher on braided natural sutures such as linen compared with synthetic materials, a factor that may further contribute to persistent tissue irritation and delayed sloughing in Group B patients."),
        ref("5"),
      ]),

      bodyPara([
        run("Group A demonstrated a shorter mean sloughing time (9.22 days) compared with Group B (11.55 days). Faster sloughing implies effective haemostasis, abbreviated foreign-body reaction, and efficient progression through granulation and epithelialization phases of wound repair. The systematic review and meta-analysis by Bhatti, Sajid, and Baig (2016), analyzing 11 RCTs encompassing 1,326 patients comparing open (Milligan-Morgan) versus closed (Ferguson) haemorrhoidectomy, reported that closed hemorrhoidectomy was associated with significantly faster wound healing (OR 0.08; 95% CI 0.02-0.24; p < 0.0001)."),
        ref("11"),
        run(" Although suture material was not the primary variable in that meta-analysis, the data underscore that wound-tissue interaction is a modifiable determinant of healing time, consistent with our observation that suture type influences the pace of tissue resolution. Ferahman (2018) further documented differential tissue responses to four different suture materials in fascial repair, confirming that suture composition and absorbability independently influence the degree and duration of local tissue reaction."),
        ref("12"),
      ]),

      bodyPara([
        run("From a surgical handling perspective, Vicryl 2-0 is supplied in a pre-sterilized pack with a pre-loaded needle, unlike Barbour linen which requires threading on to a separate needle before use. The absorbable nature of Vicryl means that once hydrolyzed, no persistent foreign material remains in the healing wound, which is advantageous over non-absorbable linen in terms of long-term tissue biocompatibility. While Vicryl 2-0 demonstrated overall better early outcomes, Barbour linen No. 20 retains clinically important advantages including higher tensile strength, making it less likely to rupture during ligation of large, engorged Grade IV haemorrhoidal pedicles. Its substantially lower cost makes it a practical choice in resource-constrained settings."),
      ]),

      bodyPara([
        run("The present findings are consistent with classical "),
        runI("Shalya Tantra"),
        run(" principles. Ayurvedic classics describe the ideal suture ("),
        runI("sutra"),
        run(") as one causing minimal tissue trauma ("),
        runI("alpa-vedana"),
        run("). The "),
        runI("Ksharasutra"),
        run(" (medicated alkaline thread), while described in classical texts for anorectal conditions, has been associated with severe postoperative pain when used for haemorrhoidal pedicle ligation in practice. A thin, synthetic, absorbable suture like Vicryl 2-0 aligns with the "),
        runI("alpa-vedana"),
        run(" principle by minimizing tissue trauma, reducing the inflammatory response, and facilitating early recovery. Research in suture material selection within the framework of "),
        runI("Shalya Tantra"),
        run(" remains sparse, and the present pilot study contributes preliminary evidence to this domain."),
      ]),

      bodyPara([
        run("The study has several limitations. The pilot design with three patients per arm is underpowered to detect statistically significant differences, and the observations are hypothesis-generating rather than conclusive. The study lacked randomization, blinding, and follow-up beyond day 14. Outcomes such as wound infection, secondary bleeding, and patient-reported quality of life were not assessed. As In (2017) noted, pilot studies are designed to inform the design and sample size of definitive trials rather than to generate practice-changing evidence."),
        ref("6"),
        run(" A larger, adequately powered, double-blind RCT with comprehensive outcome measures is warranted to confirm these findings."),
      ]),

      new Paragraph({ children:[run("")], spacing:{after:160} }),

      // ═══════════════════════════════
      //  CONCLUSION
      // ═══════════════════════════════
      sectionHead("CONCLUSION"),

      bodyPara([
        run("The choice of suture material for pedicle ligation during open haemorrhoidectomy may significantly influence early postoperative outcomes. In this pilot study, patients in the Vicryl 2-0 group experienced lower pain scores, reduced analgesic requirements, and earlier sloughing of the ligated haemorrhoidal mass compared with the Barbour linen No. 20 group. Use of an absorbable synthetic suture appears to offer advantages in terms of patient comfort and early recovery, attributable to its reduced tissue reaction profile, lower bacterial adherence potential, and improved handling characteristics. Although Barbour linen remains a stronger and more economical option, its modestly prolonged tissue response is a clinical consideration. This preliminary data provides a foundation for larger, well-designed randomized controlled trials to establish evidence-based recommendations for optimal suture selection in open haemorrhoidectomy within the framework of modern "),
        runI("Shalya Tantra"),
        run(" practice."),
      ]),

      new Paragraph({ children:[run("")], spacing:{after:160} }),

      // ═══════════════════════════════
      //  ACKNOWLEDGEMENTS
      // ═══════════════════════════════
      sectionHead("ACKNOWLEDGEMENTS"),
      bodyPara("[Authors acknowledge the guidance of their institution, the surgical team, and the patients who participated in the study.]"),

      new Paragraph({ children:[run("")], spacing:{after:160} }),

      // ═══════════════════════════════
      //  SOURCE OF FUNDING / COI
      // ═══════════════════════════════
      sectionHead("SOURCE OF FUNDING AND CONFLICT OF INTEREST"),
      bodyPara("This study received no external funding. The authors declare no conflict of interest."),

      new Paragraph({ children:[run("")], spacing:{after:160} }),

      // ═══════════════════════════════
      //  REFERENCES
      //  IJAM format: (n) inline; journal format below
      // ═══════════════════════════════
      sectionHead("REFERENCES"),

      ...[
        "1.  Bhat S. SRB's Manual of Surgery. 5th ed. New Delhi: JayPee Brothers Medical Publishers; 2016. 969p.",
        "2.  Riss S, Weiser FA, Schwameis K, Riss T, Mittlböck M, Steiner G, et al. The prevalence of hemorrhoids in adults. Int J Colorectal Dis. 2012 Feb; 27(2): 215-220.",
        "3.  O'Connell PR, McCaskie AW, Sayers RD. Bailey & Love's Short Practice of Surgery. 28th ed. Boca Raton: CRC Press; 2023. 1434p.",
        "4.  Lohsiriwat V. Hemorrhoids: from basic pathophysiology to clinical management. World J Gastroenterol. 2012 May; 18(17): 2009-2017.",
        "5.  Katz S, Izhar M, Mirelman D. Bacterial adherence to surgical sutures: a possible factor in suture induced infection. Ann Surg. 1981 Jul; 194(1): 35-41.",
        "6.  In J. Introduction of a pilot study. Korean J Anesthesiol. 2017; 70(6): 601-605.",
        "7.  Jensen MP, Chen C, Brugger AM. Interpretation of visual analog scale ratings and change scores: a reanalysis of two clinical trials of postoperative pain. J Pain. 2003 Sep; 4(7): 407-414.",
        "8.  Sakr MF. LigaSure versus Milligan-Morgan hemorrhoidectomy: a prospective randomized clinical trial. Tech Coloproctol. 2010 Mar; 14(1): 27-34.",
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        "12. Ferahman S. Tissue response to four different suture materials used to repair fascia defect in single port cholecystectomy operations. Haydarpasa Numune Train Res Hosp Med J. 2018. Available from: http://hnhtipdergisi.com/jvi.aspx?un=HNHJ-88597.",
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