Stapling procedure for haemorrhoids versus Milligan-Morgan haemorrhoidectomy: randomised controlled trial

The use of CEEA 34 in stapled hemorrhoidectomy: suggested modifications in technique

Stapled hemorrhoidectomy has been shown to be superior to conventional hemorrhoidectomy in numerous randomized, controlled trials and systemic reviews, with less postoperative pain and faster recovery. Premium Plus CEEA 34 has been recently introduced for use in stapled hemorrhoidectomy. The use of this stapler requires some modifications in technique.

[Stage-adjusted treatment for haemorrhoidal disease]

Haemorrhoidal disease is one of the most frequent disorders in western countries. The aim of individual therapy is eradication of symptoms achieved by normalisation of anatomy and physiology. Treatment is orientated to the stage of the disease: First-degree haemorrhoids are treated conservatively. In addition to high fibre diet, sclerotherapy is used. Haemorrhoids of the 2nd degree prolapse during defecation and return spontaneously. First-line treatment is rubber band ligation. Third-degree haemorrhoids that prolapse during defecation have to be digitally reduced. The majority of these patients need surgery. For segmental disorders haemorrhoidectomy according to Milligan-Morgan or Ferguson is recommended. In circular disease Stapler haemorrhoidopexy is now the procedure of choice. Using a classification orientated therapeutical regime orientated to the classification of haemorrhoidal disease offers high healing rates with a low rate of complications and recurrences.

The evaluation of CEEA 34 for stapled hemorrhoidectomy: results of a prospective clinical trial and patient satisfaction

INTRODUCTION

Stapled hemorrhoidectomy (SH) has routinely been performed using Procedure for Prolapse and Hemorrhoids Proximate Hemorrhoidal Circular Staplers (Ethicon Endo-surgery, Cincinnati, OH). Premium Plus CEEA 34 (Tyco Healthcare, New Haven, CT) has been recently introduced for SH. This study aims to review the effectiveness of CEEA 34 for SH.

METHODS

From April to June 2007, the SH procedure was performed or supervised by 5 experienced consultant surgeons. A quality of life telephone survey was performed within 4 to 6 weeks postoperatively.

RESULTS

Two hundred thirteen patients (52% men and 48% women) with a median age of 46 years (range 26-78 years) underwent SH during the trial period. Median duration of surgery was 10 minutes (range 5-35 minutes). Ninety-seven percent underwent SH for third- and fourth-degree piles. Ten patients (4.7%) had bleeding postoperatively in the first week that ceased with adrenaline injection or pack, and 2 required transfusions. Eighty-three percent participated in the quality of life survey, and 92% of these patients expressed satisfaction with the outcome of the procedure.

CONCLUSION

CEEA 34 for SH is safe and effective with few postoperative complications and high patient satisfaction.

Grade of prolapse and symptoms of haemorrhoids are poorly correlated: result of a classification algorithm in 270 patients

PURPOSE

Haemorrhoid prolapse is an indication for surgery. A correlation between worsening anatomy and increasing symptoms is commonly assumed. We developed a classification algorithm of prolapse and external component, and evaluated its correlation to symptoms before and after surgery.

METHOD

A study population comprising 180 patients operated for haemorrhoids in a multicentre randomized trial plus a validation set comprising 90 patients operated by us. The classification used three items: (i) patient self-report of prolapse requiring manual reposition; (ii) surgeon assessment of prolapse when patient negated manual reposition; (iii) surgeon assessment of external component. Patient self-reported were rated by frequency (never, 0 points; monthly, 1 point; weekly, 2 points and daily, 3 points). The algorithm yielded three grades: 1, no prolapse; 2, spontaneously reducing prolapse and 3, prolapse needing manual repositioning. The degree of external component was affixed as A, none; B, one or few tags and C, circumferential.

RESULTS

Anatomical grades did not differ between the two sets of patients before or after surgery. Preoperatively, 69% had grade 3 prolapse. Postoperatively, 89% were classified as grades 1A or B. The symptom load was similar for grades 2 and 3; mean 6.5 points preoperatively and 1.8 points postoperatively.

CONCLUSION

This anatomical classification, based on strict criteria, reliably staged the haemorrhoid prolapse. There was no unique preoperative symptom profile associated with any degree of prolapse with or without an external component. Restored anal anatomy relieved symptoms. The classification also defined recurrence of haemorrhoids.

Hemorrhoids and fissure in ano

Hemorrhoids and anal fissures are common benign anorectal conditions that form a significant part of a colorectal surgeon's workload. This review summarizes and evaluates the current techniques available in their management.

Long-term outcome of stapled hemorrhoidopexy for Grade III and Grade IV hemorrhoids

PURPOSE

This study was designed to assess the long-term results of stapled hemorrhoidopexy in 291 patients with Grade III and Grade IV hemorrhoids after a minimum follow-up of five years.

METHODS

Records of patients submitted to stapled hemorrhoidopexy for Grade III and Grade IV hemorrhoids between January 1999 and December 2002 were retrospectively analyzed. Long-term outcome was evaluated with a standardized questionnaire and an office visit, including anorectal examination and rigid proctoscopy.

RESULTS

A total of 291 patients with Grade III (57.4 percent) and Grade IV (42.6 percent) hemorrhoids were evaluated. Intraoperative (20.3 percent) and postoperative (4.8 percent) bleeding was the most frequent complication. The questionnaire was submitted to all patients at a median follow-up of 73 (range 60-93) months. There were no symptoms related to hemorrhoids in 65.3 percent of patients, moderate symptoms in 25.4 percent of patients, and severe symptoms in 9.3 percent of patients. Fifty-three (18.2 percent) patients had recurrence. Reoperation was necessary in 21 (7.2 percent) patients (4 in Grade III hemorrhoids and 17 in Grade IV hemorrhoids; P < 0.001), with no recurrent symptoms and/or prolapse. Patient satisfaction for operation was 89.7 percent.

CONCLUSIONS

Stapled hemorrhoidopexy is a safe and effective treatment for Grade III and Grade IV hemorrhoids. Recurrence requiring reoperation was higher in Grade IV hemorrhoids than in Grade III hemorrhoids.

Circular stapled hemorrhoidopexy: experience of a single center with 445 cases

This study was designed to review the results of circular stapled hemorrhoidopexy (CSH) in the management of second-, third-, and fourth-degree hemorrhoidal disease. The medical records of 483 patients who had undergone circular stapled hemorrhoidopexy for symptomatic hemorrhoidal disease from June 2001 to September 2006 were evaluated. Data regarding complications, residual symptoms, and recurrence were collected. The study included 445 patients (283 men, 162 women) between 22 and 74 years old (median age 39 years). This constituted 92% of all patients. Concomitant lateral internal sphincterotomy, skin tags' excision, and thrombus removal were done in 106 (24.0%), 83 (18.5%), and 20 (4.5%) patients, respectively. The median operating time was 24 minutes (10-45 minutes). The median hospital stay was 40 hours (11-72 hours). Complications during the first 24 hours were fecal urgency (25%), urinary retention (8%), and rectal bleeding (1%). Pruritus ani (21%), thrombosed external hemorrhoids (4%), staple line stenosis (2%), rectal bleeding (2%), anal fissure (1%), and persistent skin tags (3%) were the symptoms seen during the long-term follow-up. The median follow-up was 23 months (6-70 months). The recurrence rate was 1%. Circular stapled hemorrhoidopexy can be safely performed with low recurrence and complication rates while offering a relatively painless postoperative period for the patient.

Doppler-guided hemorrhoidal artery ligation for the treatment of symptomatic hemorrhoids: early and three-year follow-up results in 100 consecutive patients

PURPOSE

Doppler-guided ligation of the hemorrhoidal arteries was described as an alternative to hemorrhoidectomy. The authors report their experience with this procedure.

METHODS

From 2002 to 2004, 100 consecutive patients underwent hemorrhoidal artery ligation procedure for symptomatic hemorrhoids and were reviewed at one month and at three years.

RESULTS

There were 54 females. Seventy-eight patients had Grade III hemorrhoids. Eighteen patients had previously been treated for the disease. The mean operative time was 28 minutes. On average, 8.4 ligatures were placed. Seventy-nine patients were discharged the same day. Six patients presented with early complication: isolated pain in one, pain and bleeding in three, isolated bleeding in one, and obstructed defecation in one. Late complications occurred in six patients: anal pain in one, fissure in two, and thrombosis of residual hemorrhoids in three. Twelve patients presented with a recurrence at a mean delay of 12.6 months, which was treated by repeat hemorrhoidal artery ligation (n = 1), hemorrhoidopexy (n = 7), and hemorrhoidectomy (n = 4).

CONCLUSIONS

Hemorrhoidal artery ligation procedure is safe, easy to perform, and should be considered as an alternative for the treatment of symptomatic hemorrhoids, even with a recurrence rate of 12 percent, which can be treated by the same technique or another.

National UK audit of procedure for prolapsing haemorrhoids on behalf of the Association of Coloproctology of Great Britain and Ireland

OBJECTIVE

To assess the safety and short term outcomes of the procedure for prolapsing haemorrhoids (PPH), a relatively new procedure for the treatment of symptomatic haemorrhoids.

METHOD

In 2005, the Association of Coloproctology of Great Britain and Ireland set up an online electronic database to audit the indications and outcomes for patients undergoing a PPH procedure.

RESULTS

During the audit period, 695 patients were entered onto the database by 61 surgeons (range 1-50 patients per surgeon). The main indications for surgery were bleeding (90.5%) and prolapse (83.9%). Three hundred and ninety-seven (57.1%) patients had grade III or IV haemorrhoids. PPH was performed under general anaesthetic in 602 (86.6%) cases and a consultant surgeon performed the procedure in 572 (82.3%) cases. The median length of stay was 1 day (range 0-6 days). Two hundred and eighty-nine (41.6%) procedures were performed as a day case. Immediate complications were recorded in 75 (10.8%) patients, the commonest being bleeding (21) and urinary retention (24). At 6-week follow-up, 626 (90.1%) patients were pain free. Five patients required hospital re-admission for secondary haemorrhage (3), peri-anal abscess (1) and pain (1). The commonest problems were minor bleeding (48), urgency (22), pain (14), continued prolapse (12) and pruritus (11). Four patients required an open haemorrhoidectomy for persistent symptomatic haemorrhoids.

CONCLUSION

Procedure for PPH is a safe and effective procedure for symptomatic haemorrhoids with good short-term outcomes. Long-term follow-up is required perhaps through a compulsory national register.

Postoperative complications after procedure for prolapsed hemorrhoids (PPH) and stapled transanal rectal resection (STARR) procedures

Procedure for prolapsing hemorrhoids (PPH) and stapled transanal rectal resection for obstructed defecation (STARR) carry low postoperative pain, but may be followed by unusual and severe postoperative complications. This review deals with the pathogenesis, prevention and treatment of adverse events that may occasionally be life threatening. PPH and STARR carry the expected morbidity following anorectal surgery, such as bleeding, strictures and fecal incontinence. Complications that are particular to these stapled procedures are rectovaginal fistula, chronic proctalgia, total rectal obliteration, rectal wall hematoma and perforation with pelvic sepsis often requiring a diverting stoma. A higher complication rate and worse results are expected after PPH for fourth-degree piles. Enterocele and anismus are contraindications to PPH and STARR and both operations should be used with caution in patients with weak sphincters. In conclusion, complications after PPH and STARR are not infrequent and may be difficult to manage. However, if performed in selected cases by skilled specialists aware of the risks and associated diseases, some complications may be prevented.

Postoperative complications after procedure for prolapsed hemorrhoids (PPH) and stapled transanal rectal resection (STARR) procedures

Procedure for prolapsing hemorrhoids (PPH) and stapled transanal rectal resection for obstructed defecation (STARR) carry low postoperative pain, but may be followed by unusual and severe postoperative complications. This review deals with the pathogenesis, prevention and treatment of adverse events that may occasionally be life threatening. PPH and STARR carry the expected morbidity following anorectal surgery, such as bleeding, strictures and fecal incontinence. Complications that are particular to these stapled procedures are rectovaginal fistula, chronic proctalgia, total rectal obliteration, rectal wall hematoma and perforation with pelvic sepsis often requiring a diverting stoma. A higher complication rate and worse results are expected after PPH for fourth-degree piles. Enterocele and anismus are contraindications to PPH and STARR and both operations should be used with caution in patients with weak sphincters. In conclusion, complications after PPH and STARR are not infrequent and may be difficult to manage. However, if performed in selected cases by skilled specialists aware of the risks and associated diseases, some complications may be prevented.

The management of haemorrhoids

Haemorrhoidal disease is common, but there is still no consensus on optimal treatment. The most appropriate treatment is tailored to the individual patient. This article defines and classifies haemorrhoids, reviewing the efficacy of current treatments including the latest techniques.

Treatment of hemorrhoids in day surgery: stapled hemorrhoidopexy vs Milligan-Morgan hemorrhoidectomy

BACKGROUND

Recently, it has been demonstrated that surgical treatment of hemorrhoids in a day-care basis is possible and safe. The aim of this study was to compare the Longo stapled hemorrhoidopexy (SH) and the Milligan-Morgan hemorrhoidectomy (MMH).

METHODS

One hundred seventy one patients (95 cases in SH group and 76 cases in MMH group) entered the study: 83 cases were III degree hemorrhoids, 88 IV degree. A priori and a post hoc power analysis were performed. Results, prospectively collected, were compared using chi squared test and student t test. Visual analog scale was used for pain evaluation. Postoperative pain, duration of pain, wound secretion, bleeding, resumption of a normal lifestyle, and postoperative complication were evaluated.

RESULTS

Surgical time was 28.41+/-10.78 for MMH and 28.30+/-13.28 min in SH (P=0.94). Postoperative pain was not different between MMH and SH during the first two postoperative days (4.73+/-2.91 vs 5.1+/-3.048; P=0.4), during the following 6 days, patients treated with SH had less pain (4.63+/-2.04 in MMH vs 3.60+/-2.35 in SH; P=0.006). In the SH group, seven patients needed further hospital stay for complicated course. SH showed higher incidence of anal fissure compared with MMH (6.3% vs 0%; P=0.025) but no differences in urinary retention, anal stricture, urgency, or anal hemorrhage.

CONCLUSIONS

This study confirms that SH is associated with less postoperative pain and shorter postoperative symptoms, compared with MMH. SH may be a viable addition to the therapy for hemorrhoids with some advantages in early postoperative pain and some disadvantages in postoperative complications and costs.

Haemorrhoidectomy with electrocautery or ultrashears and stapled haemorrhoidopexy

BACKGROUND

This study evaluated in a randomized, prospective manner the possible differences in operative time, postoperative pain and analgesic requirement, early complications, time off-work and patient satisfaction between patients undergoing haemorrhoidectomy using the electrocautery (ECH), UltraShears (ultrasonically activated scalpel; USH) or stapled haemorrhoidopexy (SH).

METHODS

Patients with symptomatic third-degree or fourth-degree haemorrhoids were randomized into one of the three groups: ECH, SH (PPH stapler; Ethicon Endo-Surgery, Cincinnati, OH, USA) or USH groups. The operative times and complications, if any, were recorded. An identical anaesthetic technique was used for all patients, and postoperative analgesia was also standardized according to the pain scores. Pain was evaluated preoperatively and at 8 and 24 h and 2, 7, 14 and 28 days, postoperatively, by means of a visual analogue scale. The numbers of narcotic and non-narcotic analgesics used, the time required for full return to daily activities and the incontinence scores at 4 months postoperatively were evaluated, as well as patient satisfaction.

RESULTS

No significant differences with respect to age or sex existed between the three groups, each consisting of 20 patients. USH was significantly faster than both ECH and SH (P < 0.0001 for both comparisons) in operation time, and SH was faster than ECH (P < 0.0001). Comparing any two groups, the mean pain scores in the ECH group were significantly higher than in the SH and USH groups at postoperative 8 and 24 h, and day 2, but the groups reached comparable pain scores at day 7, 14 and 28. The numbers of narcotic and non-narcotic analgesics used in the ECH group were significantly higher than in the SH and USH groups (P < 0.0001 for all comparisons). The early postoperative complication rate was higher in the ECH group (25%), compared with the SH (P = 0.017) and USH (P < 0.0001) groups. Only 12 patients (60%) in the ECH group could be discharged within the first postoperative 24 h, whereas all of the patients (100%) in the SH and 17 patients (85%) in the USH groups could be treated as day cases. The time required for full return to daily activities was similar in the SH and USH groups (P = 0.841), but it was significantly longer in the ECH group (P < 0.0001 for both comparisons). The 70% patient satisfaction rate in the ECH group was significantly lower than in the SH (95%; P = 0.008) and the USH (100%, P = 0.002) groups.

CONCLUSION

Our short-term results have shown that SH and ultrasonic dissector haemorrhoidectomies were superior to ECH haemorrhoidectomy, in terms of surgical utility, postoperative pain, analgesic intake, time off-work and patient satisfaction. Some advantages of USH over SH also appeared.

Randomized clinical trial comparing day-care open haemorrhoidectomy under local versus general anaesthesia

Background

Day-care open haemorrhoidectomy under local anaesthesia (LH) may be the most cost-effective approach to haemorrhoidectomy. This prospective randomized trial compared outcome after LH from patients' and clinical perspectives with that after day-care open haemorrhoidectomy under general anaesthesia (GH).

Methods

Forty-one patients with third-degree haemorrhoids were randomized to LH (19) or GH (22). Patient demographics were comparable. A single haemorrhoid was excised in 15 patients, and two and three haemorrhoids in 13 each. Independent nurse-led assessment and clinical evaluation were carried out for 6 months. Outcome measures were mean and expected pain scores at 30, 60 and 90 min, then daily for 10 days, and satisfaction scores at 10 days, 6 weeks and 6 months. Secondary outcomes were journey time within the day-surgery unit and overall cost.

Results

Pain was worse following LH than GH at 90 min after surgery (P = 0·028), but pain scores on reaching home were similar. Maximum pain was experienced on day 3 after LH and on day 6 after GH. From day 1 onwards, daily pain scores were lower in the LH group, and there was a significant difference on day 8 (mean (95 per cent confidence interval) 3·61 (2·74 to 4·48) for LH versus 5·29 (4·12 to 6·45) for GH; P = 0·027). Mean pain over 10 days, expectation and satisfaction scores were similar in the two groups. LH had a shorter journey time and was less expensive than GH.

Conclusion

LH has similar tolerance and clinical outcome to GH, and is associated with a shorter journey time and lower cost. Registration number: NCT00503269 (http://www.clinicaltrials.gov).

Stapled technique for acute thrombosed hemorrhoids: a randomized, controlled trial with long-term results

PURPOSE

This study was designed to compare stapled vs. conventional hemorrhoidectomy for patients with acute thrombosed hemorrhoids.

METHODS

Forty-one patients with acute thrombosed hemorrhoids were randomized into: 1) stapled hemorrhoidectomy (PPH group; n = 21), and 2) open hemorrhoidectomy (open group; n = 20). Emergency surgery was performed with perioperative data and complications were recorded. Patients were followed up by independent assessors to evaluate pain, recurrence, continence function, and satisfaction at regular intervals.

RESULTS

The median follow-up for the PPH group and open group were 59 and 56 weeks, respectively. There was no significant difference in terms of the hospital stay, complication rate, and continence function; however, the mean pain intensity in the first postoperative week was significantly less in the PPH group (4.1 vs. 5.7, P = 0.02). Patients in the PPH group recovered significantly faster in terms of the time to become analgesic-free (4 vs. 8.5 days, P < 0.01), time to become pain-free (9 vs. 20.5 days, P = 0.01), resumption of work (7 vs. 12.5 days, P = 0.01), and time for complete wound healing (2 vs. 4 weeks, P < 0.01). On long-term follow-up, significantly fewer patients in the PPH group complained of recurrent symptoms (0 vs. 5, P = 0.02). The overall symptom improvement and patients' satisfaction were significantly better in the PPH group (90 vs. 80 percent, P = 0.03 and +3 vs. +2, P < 0.01 respectively).

CONCLUSIONS

Stapled hemorrhoidectomy is safe and effective for acute thrombosed hemorrhoids. Similar to elective stapled procedure, emergency stapled excision has greater short-term benefits compared with conventional excision: diminished pain, faster recovery, and earlier return to work. Long-term results and satisfaction were excellent.

Stapled hemorrhoidopexy: a technique for applying the crucial purse string suture (MAMC Technique)

BACKGROUND

Stapled hemorrhoidopexy for prolapsing hemorrhoids has been found to be associated with lesser postoperative pain and consequently earlier mobilization and return to work, in comparison to conventional hemorrhoidectomy. Purse string application remains a crucial step to ensure adequate lifting of the anal mucosa and this step is technically tedious in the presence of large hemorrhoids obscuring the vision using the standard purse string applicator. The proposed method in our technique makes this crucial step more reliable, easier, and safe in the hands of the beginner and the experienced surgeon alike.

METHODS

Thirty healthy adults (21 males and 9 females) with grade 3 or 4 hemorrhoids underwent stapled hemorrhoidopexy at a large university referral hospital in New Delhi. Purse string application was the first step in the entire procedure even before the application of the circular anal dilator. The purse string was applied using authors' method herein after referred to as Maulana Azad Medical College "(MAMC) technique" after the name of the institution. Rest of the procedure was completed as described by Longo et al.

RESULTS

The mean operative time was 26 minutes (range 16 to 40 min). The mean visual analog scale (VAS) pain score on day 1 was 1.6 (range 0 to 3). The mean hospital stay was 1.1 days (range 1 to 2 d). There was no major intraoperative complication and one case each of postoperative urinary retention and residual hemorrhoid, there was no recurrence, anal stenosis, or anal incontinence after a mean follow up of 15 months (range 3 to 24 mo).

CONCLUSIONS

The procedure described is safe, easy to learn, and technically sound, enabling the application of the crucial purse string at the desired distance from the dentate line, in the correct submucosal plane with closely placed bites and at the same transverse level.

Postoperative complications after procedure for prolapsed hemorrhoids (PPH) and stapled transanal rectal resection (STARR) procedures

Procedure for prolapsing hemorrhoids (PPH) and stapled transanal rectal resection for obstructed defecation (STARR) carry low postoperative pain, but may be followed by unusual and severe postoperative complications. This review deals with the pathogenesis, prevention and treatment of adverse events that may occasionally be life threatening. PPH and STARR carry the expected morbidity following anorectal surgery, such as bleeding, strictures and fecal incontinence. Complications that are particular to these stapled procedures are rectovaginal fistula, chronic proctalgia, total rectal obliteration, rectal wall hematoma and perforation with pelvic sepsis often requiring a diverting stoma. A higher complication rate and worse results are expected after PPH for fourth-degree piles. Enterocele and anismus are contraindications to PPH and STARR and both operations should be used with caution in patients with weak sphincters. In conclusion, complications after PPH and STARR are not infrequent and may be difficult to manage. However, if performed in selected cases by skilled specialists aware of the risks and associated diseases, some complications may be prevented.

Modified Longo's stapled hemorrhoidopexy with additional traction sutures for the treatment of residual prolapsed piles

PURPOSE

Residual prolapsed piles is a problem after the stapled hemorrhoidopexy, especially in large third- or fourth-degree hemorrhoids. We have developed a method using additional traction sutures along with modified Longo's procedure to manage this problem.

MATERIALS AND METHODS

From January 2005 to October 2005, 30 consecutive patients with symptomatic third- or fourth-degree hemorrhoids who underwent the modified Longo's stapled hemorrhoidopexy with additional traction sutures in a single institution were collected. The demographics, postoperative pain score, surgical features, outcomes, and early and late complications were recorded. All patients were followed for a mean duration of 8.8 (range, 4-15) months.

RESULTS

Thirty patients (17 males) with a mean age of 45 (range, 27-63) years were identified. The mean postoperative pain score on the morning of the first postoperative day was 2.8 (range, 1-4). The mean duration of operation was 30.7 (range, 25-37) min. The mean duration of hospital stay was 2 (range, 1-3) days. The mean days for patients to resume normal work was 6.7 (range, 4-9) days. No other procedure-related complications occurred in all patients. There was no early complication except for fecal urgency found in one patient during the first postoperative days. Regarding the late complications, no residual prolapsed piles, persistent anal pain, incontinence, anal stenosis, or recurrent symptoms were found.

CONCLUSIONS

Our preliminary experiences indicated that this modified procedures truly contributed to reduce the residual internal hemorrhoids and maintained the benefits of stapled hemorrhoidopexy. Randomized trial and long-term follow-up warrant to determine possible surgical and functional outcome.

Systematic review and meta-analysis of randomized controlled trials comparing stapled haemorrhoidopexy with conventional haemorrhoidectomy

BACKGROUND

This paper compares stapled haemorrhoidopexy with conventional haemorrhoidectomy for the treatment of haemorrhoids.

METHODS

An electronic literature search was undertaken to identify primary studies and systematic reviews. Results on efficacy and safety were analysed. A meta-analysis was conducted to examine long-term outcomes.

RESULTS

Twenty-nine randomized clinical trials recruiting 2056 patients were identified. Meta-analysis showed that stapled haemorrhoidopexy was less painful than conventional haemorrhoidectomy. Stapled haemorrhoidopexy required a shorter inpatient stay (weighted mean difference (WMD) -0.95 (95 per cent confidence interval (c.i.) -1.32 to -0.59) days; P < 0.001) and operating time (WMD -11.42 (95 per cent c.i. -18.26 to -4.59) min; P = 0.001). It was also associated with a faster return to normal activities (WMD -11.75 (95 per cent c.i. -21.42 to -2.08) days; P = 0.017). No significant difference was noted between the two techniques in terms of the total incidence of complications. Stapled haemorrhoidopexy was associated with a higher rate of recurrent disease (relative risk 2.29 (95 per cent c.i. 1.57 to 3.33); P < 0.001).

CONCLUSION

Stapled haemorrhoidopexy offers some short-term benefits over conventional operation but the total complication rates are similar for both techniques. Stapled haemorrhoidopexy is associated with a higher rate of recurrent disease.

Impact of stapled haemorrhoidopexy on stool continence and anorectal function: long-term follow-up of 242 patients

BACKGROUND AND AIMS

Several studies have proved the feasibility and safety of stapled anopexy for treating haemorrhoidal prolapse. However, stool urgency and faecal incontinence as possible side effects are still debated. Therefore, the present study was designed to assess the impact of Longo's procedure on stool continence and anorectal function.

MATERIALS AND METHODS

From 1999 to 2005, 300 patients underwent stapled haemorrhoidopexy for symptomatic haemorrhoidal prolapse. Two hundred forty-two patients (100 women, 142 men) were available for follow-up and were retrospectively reviewed. All operations were performed by one single surgeon. To evaluate anorectal function, the results of a validated incontinence score (total incontinence score [IS]: 0 = best, 20 = worst) and evacuation score (total evacuation score [ES]: 0 = worst, 28 = best) were compared pre- and postoperatively.

RESULTS

The total IS showed no difference in means before and after operation (p = 0.875, CI 95%) retrospectively. Concerning the ES, paired sample t-test showed a weak positive correlation, indicating a significant difference in score means (p = 0.041, CI 95%). The group means changed from 26.24 before operation to 26.60 after the follow-up period.

CONCLUSION

The present data revealed no significant negative impact of Longo's technique on anorectal function. In contrast, according to the evacuation score, the results showed a significant improvement of evacuation.

Initial experience with stapled hemorrhoidopexy for treatment of hemorrhoids

BACKGROUND

Introduction of stapled hemorrhoidopexy by Longo in 1998 represented a radical change in the treatment of hemorrhoids. By avoiding multiple excisions and suture lines in the perianal region, stapled hemorrhoidopexy is intended to offer less postoperative pain than with conventional techniques.

OBJECTIVE

To report and analyze the intra and postoperative results gained during initial experience with stapled hemorrhoidopexy.

METHODS

One hundred and fifty five patients (67 males) with average age of 39.5 years (21-67 years) underwent stapled hemorrhoidopexy between June 2000 and December 2003 with symptomatic third-degree (n = 74) and fourth-degree (n = 81) hemorrhoids. Mean follow-up period was 20 months (14-60 months).

RESULTS

Preoperative symptoms were prolapse (96.7%) and anal bleeding (96.1%). Overall mean operative time was 23 minutes (16-48 minutes). We observed one case of stapler failure and one case of failure to introduce the stapler occurred in a patient with previous anal surgery. Additional sutures for hemostasis were required in 103 patients (66.5%). Resection of skin tags was performed in 45 cases (29%). Postoperatively scheduled analgesia with oral dipyrone and celecoxib was enough for pain control in 131 patients (84.5%). Rescue analgesia was necessary in 24 cases (15.5%). Five patients needed opiates for pain control. Hospital discharge took place on the first postoperative day in 140 patients (90.3%). First defecation without pain was reported by 118 patients (76.1%). Postoperative complications were anal bleeding (10.3%), severe pain (3.2%), urinary retention (3.9%), fever without any signs of perianal infection (1.9%), incontinence for flatus (1.9%), hemorrhoidal thrombosis (1.3%). Two patients presented symptoms of recurrent hemorrhoidal disease and were successfully treated by conventional hemorrhoidectomy. They were no cases of anal stenosis, permanent incontinence, chronic pain or deaths in this series.

CONCLUSIONS

Hemorrhoidopexy can be considered a feasible and safe alternative technique to conventional hemorroidectomy for select patients.

Stapled hemorrhoidopexy and Milligan Morgan hemorrhoidectomy in the cure of fourth-degree hemorrhoids: long-term evaluation and clinical results

PURPOSE

The long-term results after stapled hemorrhoidopexy compared with Milligan-Morgan procedure are discussed.

METHODS

The clinical data of 100 patients treated by Milligan-Morgan procedure or stapled hemorrhoidopexy for fourth-degree hemorrhoids have been reviewed. All patients were visited and submitted to a questionnaire to evaluate resumption of symptoms, functional results, and recurrence rate.

RESULTS

The mean follow-up was 54 months for stapled hemorrhoidopexy and 92 months for the Milligan-Morgan procedure. Postoperative pain and return to normal activity were worse in the Milligan-Morgan procedure (Visual Analog Scale 8.56 vs. 5.46, P < 0.001; and 2.4 vs. 2 weeks, P value = 0.018). Eight percent of patients who had stapled hemorrhoidopexy complained of spontaneous pain or pain during defecation vs. 0 percent of patients who underwent the Milligan-Morgan procedure. We noted that there was bleeding in 14 percent of stapled hemorrhoidopexy vs. 0 percent of Milligan-Morgan procedure (P < 0.006), tenesmus in 32 percent of stapled hemorrhoidopexy vs. 0 percent of Milligan-Morgan procedure (P < 0.001), and pruritus in 4 percent of stapled hemorrhoidopexy vs. 0 percent of Milligan-Morgan procedure. Minor leakage was similar in the two groups. Flatus impaired control was less frequent in Milligan-Morgan. The relative risk of recurrence for stapled hemorrhoidopexy compared with Milligan-Morgan procedure was 1.18 (95 percent confidence interval 1< relative risk < 1.4). No statistical difference was noted in patients' satisfaction after the procedures.

CONCLUSIONS

Long follow-up seems to indicate more favorable results in Milligan-Morgan procedure in terms of resumption of symptoms and risk of recurrence.

Randomized clinical trial of LigaSure and conventional diathermy haemorrhoidectomy

BACKGROUND

The aim of this randomized prospective trial was to compare LigaSure and conventional diathermy haemorrhoidectomy.

METHODS

Two hundred and eighty-four patients with grade III or IV haemorrhoids were randomized to LigaSure or diathermy (Milligan-Morgan) haemorrhoidectomy as a day-case procedure. Operating time, postoperative pain score, hospital stay, postoperative complications, wound healing time and time to return to normal activities were assessed. Thirty-four patients were lost to follow-up.

RESULTS

The mean operating time for LigaSure haemorrhoidectomy was significantly shorter than that for diathermy (P = 0.011). Patients treated with LigaSure had significantly less postoperative pain (measured on a visual analogue scale; P = 0.010), a shorter wound healing time (defined as time to absence of swelling; P = 0.012) and less time off work (P = 0.010) than patients who had diathermy. Neither postoperative complications nor mean hospital stay (day-case surgery) were significantly different.

CONCLUSION

LigaSure haemorrhoidectomy demonstrates simplicity, reproducibility, a low complication rate, fast wound healing, a quick return to work and reduced postoperative pain.

Long-term outcome of a multicentre randomized clinical trial of stapled haemorrhoidopexy versus Milligan-Morgan haemorrhoidectomy

INTRODUCTION

Stapled haemorrhoidopexy is less painful than Milligan-Morgan haemorrhoidectomy, allowing an earlier return to working activities, but its long-term efficacy is not fully established. This study reports the long-term follow-up of a randomized clinical trial comparing the two techniques in 100 patients affected by third- and fourth-degree haemorrhoids.

METHODS

All patients were contacted and invited to attend the clinic to assess long-term functional outcome. The degree of continence and satisfaction were assessed by questionnaire. Anal manometry and anoscopy were performed.

RESULTS

Eighty patients were available after a median follow-up of 87 months. No statistically significant differences were found between the two groups in terms of incontinence, stenosis, pain, bleeding, residual skin tags or recurrent prolapse. A tendency towards a higher recurrence rate was reported in patients with fourth-degree haemorrhoids, irrespective of the technique used. No significant changes in anal manometric values were found after surgery in either group.

CONCLUSION

Both techniques are effective in the long term.

Stapled hemorrhoidopexy is associated with a higher long-term recurrence rate of internal hemorrhoids compared with conventional excisional hemorrhoid surgery

PURPOSE

The purpose of this systematic review was to compare the long-term results of stapled hemorrhoidopexy with conventional excisional hemorrhoidectomy in patients with internal hemorrhoids.

METHODS

A systematic review of all randomized, controlled trials comparing stapled hemorrhoidopexy and conventional hemorrhoidectomy with long-term results was performed by using the Cochrane methodology. The minimum follow-up was six months. Primary outcomes were hemorrhoid recurrence, hemorrhoid symptom recurrence, complications, and pain.

RESULTS

Twelve trials were included. Follow-up varied from six months to four years. Conventional hemorrhoidectomy was more effective in preventing long-term recurrence of hemorrhoids (odds ratio (OR), 3.85; 95 percent confidence interval (CI), 1.47-10.07; P < 0.006). Conventional hemorrhoidectomy also prevents hemorrhoids in studies with follow-up of one year or more (OR, 3.6; 95 percent CI, 1.24-10.49; P < 0.02). Conventional hemorrhoidectomy is superior in preventing the symptom of prolapse (OR, 2.96; 95 percent CI, 1.33-6.58; P < 0.008). Conventional hemorrhoidectomy also is more effective at preventing prolapse in studies with follow-up of one year or more (OR, 2.68; 95 percent CI, 0.98-7.34; P < 0.05). Nonsignificant trends in favor of conventional hemorrhoidectomy were seen in the proportion of asymptomatic patients, bleeding, soiling/difficultly with hygiene/incontinence, the presence of perianal skin tags, and the need for further surgery. Nonsignificant trends in favor of stapled hemorrhoidopexy were seen in pain, pruritus ani, and symptoms of anal obstruction/stenosis.

CONCLUSIONS

Conventional hemorrhoidectomy is superior to stapled hemorrhoidopexy for prevention of postoperative recurrence of internal hemorrhoids. Fewer patients who received conventional hemorrhoidectomy complained of hemorrhoidal prolapse in long-term follow-up compared with stapled hemorrhoidopexy.

Stapled hemorrhoidopexy for prolapsed hemorrhoids in patients with liver cirrhosis; a preliminary outcome for 8-case experience

PURPOSE

To investigate the efficacy and safety of stapled hemorrhoidopexy in treating prolapsed hemorrhoids in patients with liver cirrhosis.

PATIENTS AND METHODS

Eight consecutive cases of patients with prolapsed hemorrhoids comorbid with liver cirrhosis, who had intractable response to other interventions, were enrolled in this retrospective study between January 2002 and June 2006 at our institute. Six patients (75%) had Child-Pugh class A liver cirrhosis, whereas only two patients (25%) had class B disease. Rectal varices were identified in three patients (37.5%), and esophageal varices were identified in six patients (75%). Concurrent rectal and esophageal varices existed in three patients (37.5%). The patients underwent stapled hemorrhoidopexy with Proximate PPH-03 in a lithotomy position under spinal/intravenous general anesthesia.

RESULTS

There was no procedure-related mortality or major complications except hemorrhage. Two patients (25%) were complicated with postoperative staple-line bleeding, which was managed with conservative treatment without reoperation. There were no leading symptoms of relapsing during a follow-up period of at least 6 months.

CONCLUSIONS

This study may prove that stapled hemorrhoidopexy is a feasible and safe approach for prolapsed hemorrhoids concurrent with liver cirrhosis.

Randomized comparison between stapled hemorrhoidopexy and Ferguson hemorrhoidectomy for grade III hemorrhoids in Taiwan: a prospective study

PURPOSE

Short-term and mid-term outcomes of stapled hemorrhoidopexy (SH) were compared with those for Ferguson hemorrhoidectomy (FH) for treating hemorrhoids.

MATERIALS AND METHODS

Patients with prolapsed hemorrhoids were randomized into two groups treated with SH (N = 300) and FH (N = 296) at Chang Gung Memorial Hospital at Chiayi in Taiwan between January 2002 and December 2004. The outcomes of the procedures were evaluated postoperatively (short-term, i.e., intra-/postoperative conditions, hospital stay, pain intensity scoring, time off work, and procedure-related morbidity) and over a follow-up period of minimum 18 months (mid-term, i.e., relapse of prolapse and/or bleeding, anal stricture, anal sepsis, and the acceptability of the procedures to the patients).

RESULTS

SH was superior to FH in operative time, intraoperative blood loss, postoperative pain intensity, and return to work. Based on telephone interviews over the follow-up period, most patients who received SH appreciated the procedure better than those with FH.

CONCLUSIONS

This study confirms that SH generates less postoperative suffering, less time off work, and more complete resolution of primary symptoms associated with hemorrhoids in the mid-term follow-up than FH.

Stapled Hemorrhoidopexy: Outcome Assessment

Since its introduction as a new procedure for the surgical management of hemorrhoidal disease in 1993, stapled hemorrhoidopexy has become increasingly popular. This has been mostly the result of the reported reduction in postoperative pain. This study was designed to review retrospectively 152 patients combined from a 3-year period in a three-surgeon private colorectal practice and a 1-year period from an academic colon and rectal surgery training program. All patients had either grade II or III hemorrhoidal prolapse. There were 78 male (mean age, 52 years) and 74 female patients (mean age, 54 years). A total of 133 patients (87.5%) were treated on an ambulatory basis, with 131 patients (86%) given monitored sedation with local anesthesia. Postoperative complications were seen in 49 patients (32%); 33 were for bleeding, with four requiring operative control. Subsequent associated anorectal procedures were performed on 14 patients (9.2%). Of the original 152 patients, 78 participated in a postoperative survey. Of these patients, 67.9 per cent stated that their postoperative pain was less than expected. Seventy-one patients (91%) stated significant improvement or complete resolution of their symptoms, and 73.1 per cent returned to normal activity in less than 2 weeks. Eighty-nine per cent of patients surveyed stated they would recommend hemorrhoidopexy to others.

[The surgical treatment of hemorrhoids]

Surgery is the most effective treatment in patients with symptomatic grade III-IV hemorrhoids who have not responded to outpatient treatment, when there is associated abnormalities (anal fissure, anal fistula, skin tags) and in thrombosed hemorrhoids. Hemorrhoidectomy is currently the "gold standard" treatment. Randomized controlled trials comparing open with closed hemorrhoidectomy show no significant differences in pain scores. Stapled hemorrhoidectomy produces less postoperative pain than hemorrhoidectomy but is less effective in terms of symptom control. No treatment is superior to others in reducing postoperative pain except the use of drugs and anesthetic techniques. In patients with prolapsed internal hemorrhoids and thrombosed hemorrhoids, treatment may initially consist of an urgent hemorrhoidectomy with the same results as those obtained with elective surgery.

Systematic review on the procedure for prolapse and hemorrhoids (stapled hemorrhoidopexy)

PURPOSE

The procedure for prolapse and hemorrhoids (stapled hemorrhoidopexy) has been introduced as an alternative to conventional hemorrhoidectomy. This is a systematic review on stapled hemorrhoidopexy of all randomized, controlled trials that have been published until August 2006.

METHODS

All published, randomized, controlled trials comparing stapled hemorrhoidopexy to conventional hemorrhoidectomy were identified from Ovid MEDLINE, EMBASE, CINAHL, and all Evidence-Based Medicine Reviews (Cochrane Central Register of Controlled Trial, Cochrane Database of Systemic Review, and Database of Abstracts of Reviews of Effects) between January 1991 and August 2006. Meta-analysis was performed by using the Forest plot review if feasible.

RESULTS

A total of 25 randomized, controlled trials with 1,918 procedures were reviewed. The follow-up duration was from 1 to 62 months. Stapled hemorrhoidopexy was associated with less operating time (weighted mean difference, -11.35 minutes; P = 0.006), earlier return of bowel function (weighted mean difference -9.91 hours; P < 0.00001), and shorter hospital stay (weighted mean difference, -1.07 days; P = 0.0004). There was less pain after stapled hemorrhoidopexy, as evidenced by lower pain scores at rest and on defecation and 37.6 percent reduction in analgesic requirement. The stapled hemorrhoidopexy allowed a faster functional recovery with shorter time off work (weighted mean difference, -8.45 days; P < 0.00001), earlier return to normal activities (weighted mean difference, -15.85 days; P = 0.03), and better wound healing (odds ratio, 0.1; P = 0.0006). The patients' satisfaction was significantly higher with stapled hemorrhoidopexy than conventional hemorrhoidectomy (odds ratio, 2.33; P = 0.003). Although there was increase in the recurrence of hemorrhoids at one year or more after stapled procedure (5.7 vs. 1 percent; odds ratio, 3.48; P = 0.02), the overall incidence of recurrent hemorrhoidal symptoms--early (fewer than 6 months; stapled vs. conventional: 24.8 vs. 31.7 percent; P = 0.08) or late (1 year or more) recurrence rate (stapled vs. conventional: 25.3 vs. 18.7 percent; P = 0.07)--was similar. The overall complication rate did not differ significantly from that of conventional procedure (stapled vs. conventional: 20.2 vs. 25.2 percent; P = 0.06). Compared with conventional surgery, stapled hemorrhoidopexy has less postoperative bleeding (odds ratio, 0.52; P = 0.001), wound complication (odds ratio, 0.05; P = 0.005), constipation (odds ratio, 0.45; P = 0.02), and pruritus (odds ratio, 0.19; P = 0.02). The overall need of surgical (odds ratio, 1.27; P = 0.4) and nonsurgical (odds ratio, 1.07; P = 0.82) reintervention after the two procedures was similar.

CONCLUSIONS

The Procedure for Prolapse and Hemorrhoid (stapled hemorrhoidopexy) is safe with many short-term benefits. The long-term results are similar to conventional procedure.

A prospective evaluation of stapled haemorrhoidopexy/rectal mucosectomy in the management of 3rd and 4th degree haemorrhoids

OBJECTIVE

We have audited our 5 years experience of circumferential-stapled haemorrhoidopexy (PPH).

METHOD

A prospectively collected electronic data base of our 5-year experience to September 2005 has been examined.

RESULTS

A total of 357 consecutive patients (220 - 62% women, median age 46 years; range 28-92) with symptomatic third- and fourth-degree haemorrhoids (ratio 222:135) have undergone a stapled haemorrhoidopexy/rectal mucosectomy. One hundred and thirty-two (37%) had failed previous banding; 42 (12%) had undergone a Milligan-Morgan haemorrhoidectomy in the past. All but one was performed under general anaesthetic. Mean duration of surgery was 15 min (range 11-40); 299 (84%) were planned day cases (three patients were admitted overnight for pain relief (2) and retention of urine) and 57 were planned successful overnight stays. Reactive postoperative bleeding requiring a blood transfusion occurred in three patients (0.8%): one returned to theatre (0.2%). Three patients (0.8%) had a secondary haemorrhage requiring a hospital visit, one was admitted overnight. Four patients complaining of severe pain were managed in the community. Transient urgency was reported in 92 patients (26%); 58 (63%) were men, faecal impaction 4 (1.1%), minor staple line stenosis requiring dilatation 5 (1.4%), peri-anal sepsis from an associated untreated chronic anal fissure 1 (0.2%). Normal work was resumed between 3 and 31 days (median 7). Five patients re-presented with recurrent symptoms between 14 & 18 months: further treatment comprised a repeat PPH in three (one was very painful), banding 1 and reassurance alone. A further patient re-presented with minor soiling which responded to physiotherapy.

CONCLUSION

Stapled haemorrhoidopexy/rectal mucosectomy is a safe, effective and predictable treatment of third- and fourth- degree haemorrhoids and in the majority of patients can be carried out on a day case basis.

Stapled haemorrhoidopexy for prolapsed haemorrhoids: short- and long-term experience

OBJECTIVE

In prolapsed haemorrhoids, there is a permanent outward displacement of the mucosa of the anal canal, often involving the rectal mucosa. On this background, Longo set up a technique in 1998 to reduce haemorrhoidal prolapse, using a circular stapler. The aim of this study is to report our 7 years of experience on patients treated using this new surgical technique for haemorrhoids.

METHODS

Between October 1998 and June 2005, 496 patients were treated by stapled haemorrhoidopexy. We analysed data from 300 of these patients in whom follow-up was longer than 12 months.

RESULTS

The duration of the procedure ranged from 12 to 45 minutes. In 184 patients (37%), haemostatic stitches of the suture line were necessary after firing the stapler. Pain score (visual analogue scale, 1-10) after 24 hours ranged from 2 to 4 and after 5 days from 1 to 3. The average length of hospital stay was 2.3 days. Long-term results showed that only 9% of patients required further treatment after long follow-up, while 10.1% complained of some discomfort or residual symptoms in the perianal region.

CONCLUSION

Our short- and long-term results show that stapled haemorrhoidopexy for haemorrhoids is a safe procedure with less pain and lower complication rate compared to conventional haemorrhoidectomy.

Stapled hemorrhoidopexy height as outcome indicator

BACKGROUND

Postoperative expectations after stapled hemorrhoidopexy are still being clarified. Our purpose was to evaluate how outcome is affected by staple line height (SLH) above the dentate line and specimen histology.

METHODS

A prospective database identified demographics, SLH, histology, narcotic use, return to work, and resolution or recurrence of preoperative symptoms data for analysis.

RESULTS

One hundred five patients were analyzed; median age was 49 years. Median RTW and narcotic use were 9 and 4 days, respectively. Patients with squamous epithelium-containing specimens had longer narcotic use (P = .038), whereas patients with SLH >20 mm had shorter narcotic use (P = .021). Preoperative pain and bleeding resolved more frequently with SLH >20 mm (P = .036) and less frequently with SLH >40 mm (P = .032). Patients with poor sphincter tone were more likely to have SLH >20 mm (P = .044). Postoperative symptoms recurred more frequently in patients with SLH >40 mm (P = .001).

CONCLUSIONS

Hemorrhoidopexy SLH and histology can impact postoperative outcomes. SLH should be >20 mm yet < or =40 mm above the dentate, avoiding squamous epithelium.

[Haemorrhoidal suffering]

Improvements in our understanding of the anatomy of haemorrhoids have prompted the development of new and innovative methods of treatment. Conservative treatment consists of dietary and lifestyle modifications. Standard interventional procedures in outpatient treatment are injection sclerotherapy and rubber band ligation. Among the surgical options for prolapsed haemorrhoids, formal haemorrhoidectomy now competes with stapled haemorrhoidopexy, which is less painful and allows shorter convalescence but may have a higher recurrence rate and needs further long-term evaluation.

Long-term results after stapled hemorrhoidopexy: high patient satisfaction despite frequent postoperative symptoms

PURPOSE

Stapled hemorrhoidopexy has been demonstrated to be advantageous in the short term compared with the traditional techniques. We aimed to evaluate long-term results after stapled hemorrhoidopexy and to assess patient satisfaction in association with postoperative hemorrhoidal symptoms.

METHODS

This prospective study included 216 patients with Grade 2 or 3 hemorrhoids, who had stapled hemorrhoidopexy using the circular stapled technique. The results were evaluated by a standardized questionnaire at least 12 months after the operation. The primary end point was patient satisfaction; secondary end points included specific hemorrhoidal symptoms.

RESULTS

Followup data were obtained for 193 of 216 patients (89 percent) with a median follow-up of 28 (range, 12-53) months, most of whom (89 percent) were satisfied or very satisfied with the surgery. The main preoperative symptom was no longer present postoperatively in 66 percent of patients, was relieved in 28 percent, and had worsened in 2 percent. Postoperative complaints included symptoms of hemorrhoidal prolapse (24 percent of patients), anal bleeding (20 percent), anal pain (25 percent) fecal soiling/leakage (31 percent), fecal urgency (40 percent), and local discomfort (38 percent). Bivariate analysis showed significant associations between each of these symptoms and patient satisfaction. Nine patients (5 percent) were reoperated on during the follow-up period.

CONCLUSIONS

Long-term patient satisfaction was high in most of patients after stapled hemorrhoidopexy for second-degree and third-degree hemorrhoids. However, an unsatisfactory outcome was significantly related to postoperative hemorrhoidal symptoms such as prolapse, fecal soiling/leakage, and new onset of fecal urgency.

Urinary retention after haemorrhoidectomy: Impact of stapled haemorrhoidectomy

OBJECTIVE

Urinary retention is a common complication following haemorrhoidectomy. Stapled haemorrhoidectomy (SH) is associated with less postoperative pain, but whether or not this can reduce the incidence of urinary retention has not been evaluated. This study aimed to compare the incidence of urinary retention in patients treated with SH with those treated with conventional haemorrhoidectomy (CH).

METHODS

Charts of patients who underwent haemorrhoidectomy between May 2000 and March 2003 were reviewed. Data on demographics of patients, operative procedures, modes of anaesthesia, postoperative hospital stay and morbidities including urinary retention were collected. Factors that might affect the incidence of urinary retention were analysed by univariate and multivariate analyses.

RESULTS

During the study period, 204 patients (100 men and 104 women; mean age, 49 years; age range, 20-82 years) underwent haemorrhoidectomy. SH was performed in 90 (44.1%) patients while the other 114 (55.9%) had CH. Seventy patients (34.3%) were operated on as day cases. One hundred and seventeen (57.4%) patients underwent surgery under general anaesthesia and 87 (42.6%) were operated on under spinal anaesthesia. Urinary retention occurred in 31 patients (seven with SH and 24 with CH, p = 0.009). Logistic regression showed that general anaesthesia (p = 0.044; odds ratio [OR], 2.43; 95% confidence interval [CI], 1.02-5.97) and SH (p = 0.046; OR, 2.66; 95% CI, 1.02-7.00) were independent factors associated with a lower incidence of urinary retention.

CONCLUSION

The incidence of urinary retention following haemorrhoidectomy was 15.2%. General anaesthesia and SH were independent significant factors associated with a lower incidence of urinary retention.

Inflammatory polyps: a cause of late bleeding in stapled hemorrhoidectomy

PURPOSE

Stapled hemorrhoidectomy has become a popular treatment of hemorrhoids, mainly because of the benefits of greatly reduced postoperative pain. However, complications unique to the new procedure have been reported. This study was designed to review our series of 82 patients with a focus on complications, with particular focus on late bleeding caused by inflammatory polyps at the staple line.

METHODS

A review of 82 patients who underwent stapled hemorrhoidectomy was conducted. Indications included bleeding in 29 patients, prolapse in 19, combined bleeding and prolapse in 31, and pain in 3. The procedure was performed in an outpatient setting with the Ethicon ILS 33 stapler in the standard fashion.

RESULTS

Late bleeding as a result of inflammatory polyps was encountered in nine patients (11 percent). Bleeding was mild, and all cases resolved after excision of the polyps. Other complications occurred with the following frequency: urinary retention (4.9 percent), submucosal hematoma (2.4 percent), early bleeding (1.2 percent), recurrent hemorrhoids (2.4 percent), thrombosed external hemorrhoids (2.4 percent), and fecal urgency (3.7 percent).

CONCLUSIONS

Bleeding from inflammatory polyps occurs in a significant number of patients undergoing stapled hemorrhoidectomy. Mild bleeding several weeks or months after the procedure should prompt a search for inflammatory polyps at the staple line. Simple excision of the polyps was adequate treatment and has not resulted in rebleeding.

Perianal local block for stapled anopexy

PURPOSE

This study was designed to demonstrate the usefulness of a method of regional anesthesia for circular stapler anopexy for prolapsing hemorrhoids.

METHODS

Thirty-three patients consented to stapled anopexy under perianal local anesthesia. Eighteen patients with stapled anopexy under general anesthesia were controls. The perianal block was applied with 40 ml of ropivacaine, 4.75 mg/ml, injected immediately peripheral to the external sphincter. A submucosal block with 15 ml of ropivacaine, 2 mg/ml, was added after applying the pursestring suture. Postoperative pain was rated by the patient for 14 days by using a ten-point visual analogue scale. Patients also submitted a preoperative and postoperative (3-6 months) symptom questionnaire to rate anal symptoms.

RESULTS

No operation was converted to general anesthesia. Operation time was similar in both groups. All patients in the local anesthesia group were pain free at discharge. The sums of pain scores during 14 days for daily average pain and peak pain were similar in both groups (average pain 23 (local anesthesia) vs. 35 (general anesthesia); peak pain 39 (local anesthesia) vs. 50 (general anesthesia); P>0.05). The preoperative symptom scores were 7.8 (local anesthesia) vs. 8.9 (general anesthesia) points, and the follow-up scores were 2.2 (local anesthesia) and 2.7 (general anesthesia), a significant improvement (P=0.001) in both groups but not different between groups.

CONCLUSIONS

A perianal local block is easy to apply and has a high degree of acceptance among patients. The operation time, postoperative pain, and success rates of the operation equaled those of stapled anopexy performed under general anesthesia. The advantages are quicker turnover between cases and simpler management of pain-free postoperative patients in day surgery.

Rectal stenosis after procedures for prolapse and hemorrhoids (PPH)--a report from China

OBJECTIVES

After it was introduced in China in 2000, the surgical procedure for prolapse and hemorrhoids (PPH) has become a widely accepted for third- and fourth-degree hemorrhoids. Stenosis of the lower rectum is one of the delayed complications. In order to evaluate this specific problem following PPH, we reviewed our data with special reference to potential predictive factors or stenotic events.

METHODS

A retrospective analysis of 554 consecutive patients that underwent PPH from July 2000 to December 2004 was performed. Only patients with follow-up check were evaluated; therefore 65 patients (11.7%) Hwere lost to follow-up, and the analysis therefore includes 489 patients with a mean follow-up of 324 days (+/-18 days). For statistical analysis, the groups with and without stenosis were evaluated using the chi-square test; using the Kaplan-Meier statistic, the actuarial incidence for rectal stenosis was plotted.

RESULTS

Rectal stenosis was observed in 12 patients (2.5%) in whom the median time to stenosis was 125 (89 approximately 134) days. All patients complained of obstructive defecation and underwent strictureplasty with electrocautery or balloon dilation through colonoscopy. A statistical analysis revealed that two factors were significantly more prevalent among patients with stenosis: prior sclerosis therapy for hemorrhoids (P=0.02) and severe postoperative pain (P=0.003). Other factors, such as gender (P=0.32), prior surgery for hemorrhoids (P=0.11), histological evidence of squamous skin (P=0.77) or revision (P=0.53) showed no significance.

CONCLUSIONS

Rectal stenosis is an uncommon event after PPH. Early stenosis will occur within the first 4 months after surgery. In most cases, the stenosis can be cured through colonoscopy surgery. Predictive factors for stenosis are previous sclerosis therapy for hemorrhoids and severe postoperative pain.

New techniques in the treatment of common perianal diseases: stapled hemorrhoidopexy, botulinum toxin, and fibrin sealant

There have been several recent advances in the treatment of common perianal diseases. Stapled hemorrhoidopexy is a procedure of hemorrhoidal fixation, combining the benefits of rubber band ligation into an operative technique. The treatment of anal fissure has typically relied upon internal sphincterotomy; however, it carries a risk of incontinence. The injection of botulinum toxin represents a new form of sphincter relaxation, without division of any sphincter muscle; morbidity is minimal and results are promising. For the treatment of fistula in a fistulotomy remains the gold standard, however, it carries significant risk of incontinence. Use of fibrin sealant to treat fistulae has been met with variable success. It offers sealing of the tract, and then provides scaffolding for native tissue ingrowth.

Stapled versus conventional surgery for hemorrhoids

BACKGROUND

Hemorrhoids are one of the most common anorectal disorders. The Milligan‐Morgan open hemorrhoidectomy is the most widely practiced surgical technique used for the management of hemorrhoids and is considered the current "gold standard". Circular stapled hemorrhoidopexy was first described by Longo in 1998 as alternative to conventional excisional hemorrhoidectomy. Early, small randomized‐controlled trials comparing stapled hemorrhoidopexy with traditional excisional surgery have shown it to be less painful and that it is associated with quicker recovery. The reports also suggest a better patient acceptance and a higher compliance with day‐case procedures potentially making it more economical. A previous Cochrane Review of stapled hemorrhoidopexy and conventional excisional surgery has shown that the stapled technique is associated with a higher risk of recurrent hemorrhoids and some symptoms in long term follow‐up. Since this initial review, several more randomized controlled trials have been published that may shed more light on the differences between the novel stapled approach and conventional excisional techniques.

OBJECTIVES

This review compares the use of circular stapling devices and conventional excisional techniques in the surgical treatment of hemorrhoids. Its goal is to ascertain whether there is any difference in the outcomes of the two techniques in patients with symptomatic hemorrhoids.

SEARCH STRATEGY

We searched all the major electronic databases (MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) from 1998 to December 2009.

SELECTION CRITERIA

All randomized controlled trials comparing stapled hemorrhoidopexy to conventional excisional hemorrhoidal surgeries with a minimum follow‐up period of 6 months were included.

DATA COLLECTION AND ANALYSIS

Data were collected on a data sheet. When appropriate, an Odds Ratio was generated using a random effects model.

MAIN RESULTS

Patients with SH were significantly more likely to have recurrent hemorrhoids in long term follow up at all time points than those with CH (12 trials, 955 patients, OR 3.22, CI 1.59‐6.51, p=0.001). There were 37 recurrences out of 479 patients in the stapled group versus only 9 out of 476 patients in the conventional group. Similarly, in trials where there was follow up of one year or more, SH was associated with a greater proportion of patients with hemorrhoid recurrence (5 trials, 417 patients, OR 3.60, CI 1.24‐10.49, p=0.02). Furthermore, a significantly higher proportion of patients with SH complained of the symptom of prolapse at all time points (13 studies, 1191 patients, OR 2.65, CI 1.45‐4.85, p=0.002). In studies with follow up of greater than one year, the same significant outcome was found (7 studies, 668 patients, OR 3.14, CI 1.20‐8.22, p=0.02). Patients undergoing SH were more likely to require an additional operative procedure compared to those who underwent CH (8 papers, 553 patients, OR 2.75, CI 1.31‐5.77, p=0.008). When all symptoms were considered, patients undergoing CH surgery were more likely to be asymptomatic (12 trials, 1097 patients, OR 0.59, CI 0.40‐0.88). Non significant trends in favor of SH were seen in pain, pruritis ani, and fecal urgency. All other clinical parameters showed trends favoring CH.

Prospective randomized trial comparing stapled hemorrhoidopexy versus closed Ferguson hemorrhoidectomy

Background

Ferguson hemorrhoidectomy is believed to result in less postoperative pain because of a closed wound. Stapled hemorrhoidopexy, without a perianal wound, should thus have lesser pain. We conducted a prospective randomized trial to compare stapled hemorrhoidopexy (SH) with Ferguson hemorrhoidectomy (FH).

Methods

Fifty patients with third-degree or early fourthdegree hemorrhoids who required surgery were recruited. Patients were prospectively randomized to receive either FH or SH. Data collected include operative time, hospital stay, fecal incontinence and pain scores, morbidity and complications.

Results

SH patients had less pain in the early postoperative period. There were no significant differences in hospital stay or major complications. One patient after SH required emergency reintervention for thrombosed hemorrhoids distal to the staple line. FH patients had more minor problems of bleeding, wound discharge and pruritus. Fecal incontinence was similar in the 2 groups but two of the three patients with daily incontinence to gas after SH claimed that their lifestyle was affected.

Conclusions

SH is safe to perform and results in less postoperative pain as well as less minor morbidity. Early reintervention and incontinence to gas compromising lifestyle occurred only after SH.