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

Therapie des Hämorrhoidalleidens

Hemorrhoidal disease is one of the most frequent disorders in western countries. The aim of individual therapy is freedom from symptoms achieved by normalisation of anatomy and physiology. Treatment is orientated to the stage of disease: haemorrhoids 1 are treated conservatively. In addition to high-fibre diet, sclerotherapy is used. Haemorrhoids 2 prolapse during defecation and return spontaneously. First-line treatment is rubber band ligation. Haemorrhoids 3 that prolapse during defecation have to be digitally reduced, and the majority need surgery. For segmental disorders, haemorrhoidectomy according to Milligan-Morgan or Ferguson is recommended. In circular disease, Stapler hemorrhoidopexy is now the procedure of choice. Using a therapeutic regime according to the hemorrhoidal disease classification offers high healing rates and low rates of complications and recurrence.

Prospective Randomized Clinical Trial Comparing Two Different Circular Staplers for Mucosectomy in the Treatment of Hemorrhoids

BACKGROUND

The main objections against circular stapled mucosectomy have been anal pain and rectal bleeding during the surgical procedure or in the immediate postoperative follow-up. To avoid these consequences, a new stapler (PPH33-03) has been developed. The aim of this trial was to compare the intraoperative and short-term postoperative morbidity of stapled mucosectomy with PPH33-01 versus PPH33-03 in the treatment of hemorrhoids.

METHODS

We conducted a prospective randomized clinical trial comparing hemorrhoidectomy with PPH33-01 (group 1, n=30) versus PPH33-03 (group 2, n=30) for grade III-IV symptomatic hemorrhoids. For the follow-up, the patients underwent examination and proctoscopy at 4 weeks, 3 months, and 6 months. We recorded anal pain (linear analog scale from 0 to 10), intraoperative hemorrhage, postoperative bleeding, and continence (Wexner Continence Grading Scale).

RESULTS

Demographic and clinical features showed no differences between the two groups. More patients required suture ligation to stop anastomotic bleeding at surgery when the PPH33-01 stapler was used (15 versus 4, P<0.05). Rectal bleeding during the first postoperative 4 weeks was similar (P>0.05). The postoperative pain scores during the first week were similar (P>0.05). Patients with pain on defecation were fewer in the PPH-03 group (15 versus 2, P<0.05). Six patients from group 1 and none from group 2 (P<0.05) had granulomas along the line of staples at the sites of the reinforcing stitches; the granulomas were associated with postoperative anal discomfort and rectal bleeding. One patient in group 1 complained of persistent pain that resolved within 3 months. Of all the intraoperative or preoperative variables analyzed, only the presence of granuloma was associated with postoperative bleeding and anal discomfort. We have not found any recurrence or incontinence during the 6-month follow-up.

CONCLUSIONS

Intraoperative bleeding along the stapled line and tenesmus or discomfort during defecation were less frequent after circular stapled mucosectomy with PPH33-03. Therefore, circular stapled mucosectomy with PPH33-03 decreases the risk of immediate complications and thus allows implantation with more safety as a day surgery procedure.

Controversies in the treatment of common anal problems

Treating common benign anal diseases has evolved towards more outpatient procedures with better outcome. However, minimizing post-procedure morbidities such as pain and the avoidance incontinence remain the most significant concerns. We introduce some controversies and highlight the developments in current surgical practice for the treatment of common anal problems.

[Postoperative pain and long-term results after hemorrhoidal treatment with anopexy]

AIMS

Anopexy allows treatment of hemorrhoidal symptoms with a less painful postoperative course. This information is important for the patient, but may lead to dissatisfaction if pain level is higher than expected. To evaluate perceived pain and physical limitation levels in relation to patient's expectation. Evaluate long-term functional results.

RESULTS

Sixty-eight consecutive patients (56 males) were prospectively included. Distribution of haemorrhoid grades were 4 grade 2 (6%), 52 grade 3 (76%) and 12 grade 4 (18%). Postoperative pain level was less or equal than expected for 85% of patients, with a better acceptance superior to 45 years. Physical limitation was equally or less important than expected for 89%. At the 32 weeks follow-up hemorrhoidal symptoms were present in 23%, uninfluenced by any patient's or operative characteristics. Incontinence with urgency was reported by 17%. Presence of an alliterated continence was linked to stapled line inferior to 6,5 mm from pectineate line, doughnut height inferior to 22 mm, external hemorrhoids and related to surgeon.

CONCLUSION

Pragmatic information, although vague, about postoperative pain does not expose to patient's dissatisfaction. Functional results are not influenced by technical variation. Continence alterations are not severe, but frequent when stapled line is too close from pectineate line.

The safety and efficacy of stapled hemorrhoidectomy in the treatment of hemorrhoids: a systematic review and meta-analysis of ten randomized control trials

AIMS

The objective of this study was to compare the safety and efficacy outcomes of stapled hemorrhoidectomy (PPH) with Milligan-Morgan hemorrhoidectomy (MMH) in the treatment of severe hemorrhoids.

METHODS

A meta-analysis pooled the effects of the safety and efficacy outcomes on PPH, and MMH in ten randomized control trials was presented using a fixed effects model or a random effects model (via RevMan Version 4.2).

RESULTS

There was reasonably clear evidence in favor of PPH for operating time, length of hospital stay, pain, anal discharge, and patient satisfaction. However, skin tags and prolapse occurred at higher rates in the PPH group. PPH was not more superior than MMH as to postoperative bleeding, urinary retention, difficulty in defecating, anal fissure and stenosis, sphincter damage, resumption of normal activities, incontinence, pruritus, anal resting and squeeze pressures, and analgesia.

CONCLUSIONS

PPH may be at least as safe as MMH. However, the efficacy of PPH compared with MMH could not be determined absolutely. More rigorous studies with longer follow-up periods and larger sample sizes need to be conducted.

Experience of 3711 stapled haemorrhoidectomy operations

BACKGROUND

Stapled haemorrhoidectomy has been routinely performed in the Department of Colorectal Surgery, Singapore General Hospital since 1999.

METHODS

A retrospective review was undertaken of all patients who underwent stapled haemorrhoidectomy between October 1999 and May 2004. The outcomes studied were patient profiles, priority of operation, indications for surgery, length of operation, postoperative complications and recurrences.

RESULTS

A total of 3711 patients (51.1 per cent women) had the surgery. The median patient age was 50 (range 18-88) years. The main indications were bleeding (80.7 per cent), haemorrhoidal prolapse (59.6 per cent) and thrombosis (3.9 per cent). The median duration of operation was 15 (range 5-45) min. Minor complications occurred in 12.3 per cent of patients: acute retention of urine (4.9 per cent), bleeding (4.3 per cent), significant postoperative pain requiring admission (1.6 per cent), anorectal stricture (1.4 per cent), perianal haematoma (0.05 per cent) and significant residual skin tags (0.05 per cent). One patient developed a perianal abscess after stapled haemorrhoidectomy. Anastomotic dehiscence occurred in three patients (0.08 per cent). Twelve (0.3 per cent) patients had a recurrence at a median of 16 (range 5-45) months.

CONCLUSION

Considerable experience of stapled haemorrhoidectomy confirms it as a safe and effective procedure.

Stapled haemorrhoidopexy in fourth degree haemorrhoidal prolapse: is it worthwhile?

INTRODUCTION

Ten years after the introduction of stapled haemorrhoidopexy few studies have stratified patients by degree of haemorrhoidal disease when analysing results. Objective The aim of this study was prospectively to evaluate 116 patients who underwent stapled anopexy conducted by the same surgeon for III or IV degree haemorrhoidal prolapse.

MATERIALS AND METHODS

One hundred and sixteen consecutive patients affected by symptomatic haemorrhoids of III or IV degree underwent stapled anopexy using the technique described by Longo in the period January 2001 to October 2003. Mean follow-up was 28.1 months. Fischer's exact test was used for statistical analysis. Results, in terms of morbidity and recurrence rates, were stratified according to degree of haemorrhoidal disease.

RESULTS

There was no statistically significant difference between the results for third degree compared with fourth degree prolapse although there was a trend towards increased incidence of postoperative bleeding and recurrence.

CONCLUSION

Third degree haemorrhoidal prolapse remains the best indication for stapled haemorrhoidopexy. This procedure may also be indicated in fourth degree haemorrhoidal prolapse. Patients with fourth degree haemorrhoids may be subjected to this procedure following adequate discussion of the outcome.

Stapled haemorrhoidopexy for haemorrhoids in combination with lateral internal sphincterotomy for fissure-in-ano

The aim of this prospective study is to describe the combined technique and results of stapled haemorrhoidopexy and lateral internal sphincterotomy for patients suffering from prolapsing 3rd-degree haemorrhoids and chronic fissure-in-ano. During the period from 1999 to 2004, 26 patients underwent combined surgical treatment for anal fissure and prolapsing symptomatic haemorrhoids. Preoperative and postoperative clinical evaluation and the patient's degree of satisfaction were recorded. Early complications included faecal urgency (3 patients) and pain (2 patients). Complete continence was restored within 10 weeks in all patients except 1 who had persisting incontinence to flatus. All fissures healed completely within 4 weeks. No haemorrhoidal or fissure recurrence has been observed during follow-up. The combination of stapled haemorrhoidopexy and lateral internal sphincterotomy is a safe and effective procedure for the treatment of prolapsing 3rd-degree haemorrhoids and chronic anal fissures.

Day case stapled haemorrhoidopexy for prolapsing haemorrhoids

OBJECTIVE

Conventional surgical management of prolapsing haemorrhoids is by excisional haemorrhoidectomy. Postoperative pain has restricted the application of such procedures in the day case setting. These operations remain associated with a period of restricted activity. The use of circular stapling devices as an alternative to the excisional approach in the management of haemorrhoids has been described. This study reports our experience of stapled haemorrhoidopexy as a day case procedure.

METHODS

Patients with third or fourth degree haemorrhoids were eligible for the procedure. Patients were considered suitable candidates for day case surgery based on conventional parameters. Symptoms were assessed using a previously validated symptom severity rating score. Stapled haemorrhoidopexy was carried out using a circular stapling device. Pain scores were obtained prior to discharge. Patients were admitted if pain was uncontrolled despite oral analgesia. Symptoms were re-scored at six-week follow-up.

RESULTS

Over a 70-month period 168 consecutive stapled haemorrhoidopexies were performed or directly supervised by one consultant colorectal surgeon. One hundred and ten (65%) patients were considered appropriate candidates for day case surgery by conventional criteria. Ninety-six (87.3%) patients successfully underwent stapled haemorrhoidopexy on a day case basis. Fourteen (12.7%) patients required admission on the day of surgery (5 for early postoperative bleeding, 4 for pain necessitating continuing opiate analgesia, two for urinary retention and three for surgery performed late in the day). Six (5%) patients were re-admitted postoperatively; four for pain relief and two because of urinary retention. Of the day case patients, 91 (82.7%) and 56 (50.9%) had been seen for 6 week and 6 month review, respectively, at the time of analysis. Symptom scores were 6 (pre-operatively) vs 0 (postoperatively) (P < 0.01). 76/91 (83.5%) patients reviewed at 6/52 were asymptomatic.

CONCLUSION

Stapled haemorrhoidopexy is a safe and effective procedure that can be carried out on selected patients on a day case basis. Complications are of a similar nature to excisional haemorrhoidectomy.

Prospective randomised clinical trial of single versus double purse-string stapled mucosectomy in the treatment of prolapsed haemorrhoids

BACKGROUND AND AIMS

Despite the excellent results published on circular stapled mucosectomy (CSM), there is still some concern about the application of PPH-33 in the advanced haemorrhoidal disease, where a major prolapse may lead to insufficient resection and ensuing early recurrence. This study is aimed at comparing the outcomes after single purse-string CSM versus double purse-string CSM.

PATIENTS AND METHODS

A prospective randomised clinical trial of single versus double purse-string CSM for grade III-IV symptomatic haemorrhoids was used. One hundred consecutive patients were randomised to single (group 1, N=50) versus double purse-string CSM (group 2, N=50).

RESULTS

The mean age was 50.7 years, with a predominance of males (63 vs. 37). Haemorrhoids were classified as grade III in 59% and grade IV in 41% of the patients. Mean follow-up was 26 months. Demographic and clinical features showed no differences between the two groups. The size of the resected doughnut was greater in group 2 (4.95 vs. 3.55 cm; p<0.05), as was the distance of the suture from the dentate line (3.56 vs. 3.16 cm; p<0.05). Early postoperative pain was significantly less in group 2 (linear analogue scale from 0 to 10), 2.08 vs. 3.56 (p<0.001). Postoperative haemorrhage was absent or minimal in 79% of patients. Three patients from group 1 reported persistent pain that was resolved within the first few postoperative months. There were two recurrences in group 1.

CONCLUSION

Double purse-string CSM resects a greater doughnut, increases the distance of the staple suture from the dentate line and reduces early postoperative pain in comparison to single purse-string CSM. Larger series are necessary to assert whether recurrence is lower.

Prospective randomized clinical trial on suction elastic band ligator versus forceps ligator in the treatment of haemorrhoids

OBJECTIVE

This prospective randomized clinical trial was undertaken to compare the use of a single-operator vacuum suction ligator and the traditional forceps ligator in terms of pain perception following the procedure, intra-procedure bleeding and other complications.

METHODS

One hundred consecutive patients with second- and third-degree haemorrhoids presenting between July 2002 and September 2003 were randomized into suction and forceps groups for rubber band ligations. They were equally distributed in both groups, with a mean age of 48.7 years (range, 15-83 years). The immediate, 24-hour, 7-day and 14-day pain scores after the procedure were evaluated using a visual analogue scale. Intra-procedure bleeding and other complications at follow-up were evaluated.

RESULTS

Pain perception was worse in the forceps group immediately after ligation, with a mean score of 6.08 compared with 3.08 in the suction group (p < 0.001). Pain score remained high among the forceps patients at 24 hours post-banding, with a mean score of 4.00 compared with 1.92 in the suction group (p < 0.001). There was no significant difference in terms of immediate and 24-hour pain perceptions whether two or three haemorrhoids were banded per session (p = 0.904 and p = 0.058). The amount of analgesia consumed after banding correlated well with the severity of pain reported, being higher among the forceps group with a mean of 4.48 tablets (p = 0.003). Intra-procedure bleeding occurred in 25 patients in the forceps group compared with five in the suction group (p < 0.001). There were no severe complications such as perianal sepsis, urinary retention, sphincter dysfunction or bleeding during the trial.

CONCLUSION

Suction band ligation is superior to forceps ligation for the treatment of second- and third-degree haemorrhoids in terms of pain tolerance, amount of analgesia consumed and intra-procedure bleeding.

Stapled haemorrhoidectomy: bothersome staple line bleeding

BACKGROUND

The stapled haemorrhoidectomy procedure has been popularized as a painless and effective treatment for prolapsing haemorrhoidal disease. We have noted that staple line bleeding is a contributory factor to postoperative morbidity.

METHODS

This was a retrospective analysis of the clinical records of consecutive stapled haemorrhoidectomy procedures performed in patients over a 1-year period. The outpatient, operative and inpatient records were reviewed. We assessed the incidence of intraoperative staple line bleeding, its management and early postoperative outcomes in our patients undergoing stapled haemorrhoidectomy.

RESULTS

From March 2000 to March 2001, 39 stapled haemorrhoidectomy procedures were performed. Intraoperative staple line bleeding was recorded in 17 patients (44%) and suture reinforcement of this staple line was required in 12 (31%). Nine patients (23%) were admitted for postoperative per rectal bleeding, four of whom required surgical haemostasis of bleeding points along the staple line. Delayed secondary haemorrhage was seen in one patient. The incidence of postoperative bleeding in patients with noted staple line bleeding was 35%, compared with 14% in those without evidence of bleeding.

CONCLUSION

Staple line bleeding is a technical difficulty and complication associated with stapled haemorrhoidectomy. It should be managed with meticulous haemostatic suture placement in order to avoid postoperative bleeding and the morbidity of re-operation for haemostasis.

Stapled hemorrhoidectomy: present status

AIM: To evaluate cost-effectiveness of stapled hemorrhoidectomy comparing its results with conventional technique. SOURCE OF DATA: We retrospectively analyzed the MEDLINE data basis from 2000 to 2004 studying randomized clinical trials which compared pain intensity, recovery period, return to work and occurrence of anal incontinence, in addition to postoperative complications and costs evaluation between stapled and conventional hemorrhoidectomy during different periods of follow-up. CONCLUSIONS: Stapled hemorrhoidectomy provides lesser postoperative pain and earlier return to work than conventional hemorrhoidectomy. However, its efficacy could not be determined, since rigorous prospective and randomized clinical trials with long-term follow-up periods and large size samples are not available at this time.

Stapled hemorrhoidopexy versus milligan-morgan hemorrhoidectomy: a prospective, randomized, multicenter trial with 2-year postoperative follow up

PURPOSE

The purpose of this study was to compare the outcome of stapled hemorrhoidopexy (SH group) performed using a circular stapler with that of the Milligan-Morgan technique (MM group). The goals of the study were to evaluate the efficacy and reproducibility of stapled hemorrhoidopexy and define its place among conventional techniques.

METHODS

A series of 134 patients were included at 7 hospital centers. They were randomized according to a single-masked design and stratified by center (with balancing every 4 patients). Patients were clinically evaluated preoperatively and at 6 weeks, 1 year, and a minimum of 2 years after treatment. Patients completed a questionnaire before and 1 year after surgery to evaluate symptoms, function, and overall satisfaction.

RESULTS

The mean follow-up period was 2.21 years +/- 0.26 (1.89-3.07). Nine patients (7%) could not be monitored at 1 or 2 years, but 4 of these 9 nevertheless filled in the 1-year questionnaire. The patients in the SH group experienced less postoperative pain/discomfort as scored by pain during bowel movement (P < 0.001), total analgesic requirement over the first 3 days (according to the World Health Organization [WHO] class II analgesics [P = 0.002]; class III [P = 0.066]), and per-patient consumption frequency of class III analgesics (P = 0.089). A clear difference in morphine requirement became evident after 24 hours (P = 0.010). Hospital stay was significantly shorter in the SH group (SH 2.2 +/- 1.2 [0; 5.0] versus MM 3.1 +/- 1.7 [1; 8.0] P < 0.001). At 1 year, no differences in the resolution of symptoms were observed between the 2 groups, and over 2 years, the overall incidence of complications was the same, specifically fecaloma (P = 0.003) in the MM group and external hemorrhoidal thrombosis (P = 0.006) in the SH group. Impaired sphincter function was observed at 1 year with no significant difference between the groups for urgency (12%), continence problems (10%), or tenesmus (3%). No patient needed a second procedure for recurrence within 2 years, although partial residual prolapse was detected in 4 SH patients (7.5%) versus 1 MM patient (1.8%) (P = 0.194).

CONCLUSION

Stapled hemorrhoidopexy causes significantly less postoperative pain. The technique is reproducible and can achieve comparable outcomes as those of the MM technique as long as the well-described steps of the technique are followed. Like with conventional surgery, anorectal dysfunction can occur after stapled hemorrhoidopexy in some patients. Its effectiveness in relieving symptoms is equivalent to conventional surgery, and the number of hemorrhoidal prolapse recurrences at 2 years is not significantly different. Hemorroidopexy is applicable for treating reducible hemorrhoidal prolapse.

Stapled transanal rectal resection for obstructed defaecation and evidence-based practice

A cautious approach is advocated

Radiographic findings of post-operative double stapled trans anal rectal resection (STARR) in patient with obstructed defecation syndrome (ODS)

Longo's procedure of double stapled trans anal rectal resection (STARR) has been evocated as surgical treatment of the obstructed defecation syndrome (ODS) in patients with rectal mucosal prolapse. The aim of this study was to investigate the post-interventional findings of this technique, to help radiologist in knowledge of the changed morphology of the rectal lumen, also in attempt to recognize some potential related complications.

Local anesthesia for stapled prolapsectomy in day surgery: results of a prospective trial

PURPOSE

This article reports the results of a prospective trial of the feasibility of Longo's procedure under local anesthesia in day surgery.

METHODS

From April 2002 to May 2003, 66 patients (42 males and 24 females) were enrolled in the study; the mean age was 47.5 (range, 23-65) years. Thirty-six patients (55 percent) had prolapsed third-degree hemorrhoids, while 30 (45 percent) had fourth-degree hemorrhoids. All patients were operated on under local infiltration of the anorectal region by injecting ropivacaine 7.5 mg/dl using a Quadrijet. During the surgical procedure, blood pressure and heart rate were always monitored and the level of pain was checked using a visual analog scale. Hospital discharge was programmed for 6:00 p.m. Any immediate complications, such as bleeding, urinary retention, or pain, were also recorded.

RESULTS

It was possible to perform the procedure under local anesthesia in all patients, and the anesthesiologist did not need to intervene at any time. No vagal reaction was observed; the transient reduction of blood pressure and heart rate, which occurred in four patients (6 percent),was controlled with an analgesic drug. In 96 percent of the cases the mean intraoperative visual analog score was not higher than four. Fifty-six patients were discharged at 6:00 p.m., while only 10 percent required an overnight stay.

CONCLUSIONS

The stapled prolapsectomy procedure is feasible and can be performed safely under local anesthesia and as day surgery. This procedure provides good pain control and results in a minimal number of complications.

Stapled hemorrhoidectomy

Stapled hemorrhoidectomy has rapidly evolved and become the procedure of choice for primarily internal hemorrhoids. Even though the technique is relatively straightforward, only strict adherence to its principles will avoid serious complications and preserve the previously described benefits of this method. Recurring questions during teaching courses as well as several pitfalls that might result in suboptimal outcomes have prompted us to highlight some important details and modifications of the surgical technique.

Complications of stapled hemorrhoidectomy: a French multicentric study

OBJECTIVES

The aim of this retrospective multicentric study was to assess the complications of the Longo technique for the treatment of haemorrhoidal disease.

METHODS

From March 1999 to April 2003, 550 patients underwent a stapled hemorrhoidectomy following Longo's technique in 12 surgical units in the Rhone-Alpes Region. The operative indications were the same as for conventional hemorrhoidectomy. Complications were divided into early or late complications depending on whether they occurred before or after the 7th day. For each patient, the most serious complication was retained for analysis.

RESULTS

One hundred and five patients (19%), mean age 51 years, experienced complications. The early complications were bleeding (1.8%), severe anal pain (2.3%), urinary retention (0.9%) and sepsis (0.5%). Late complications were chronic anal pain (1.6%), suture dehiscence (1.6%), anal stricture (1.6%), anal fissure (0.9%), external thrombosis (0.9%), fistulae and intramural abscesses (0.9%), anal incontinence (0.3%), haemorrhoidal disease symptoms persistence or recurrence (3.2%). Strictures were successfully dilated, fissures were treated by sphincterotomy, external thromboses were excised and fistulae were laid open. Most of the recurrences were treated with the Milligan-Morgan hemorroidectomy technique.

CONCLUSION

Complications may occur after stapled hemorrhoidopexy, some are particularly serious, especially bleeding and sepsis.

Stapled hemorrhoidopexy vs. Harmonic Scalpel hemorrhoidectomy: a randomized trial

PURPOSE

A randomized trial was undertaken to evaluate and compare stapled hemorrhoidopexy with excisional hemorrhoidectomy in which the Harmonic Scalpel was used.

METHODS

Patients with Grade III hemorrhoids who were employed during the trial period were recruited and randomized into two groups: (1) Harmonic Scalpel hemorrhoidectomy, and (2) stapled hemorrhoidopexy. All operations were performed by a single surgeon. In the stapled group, the doughnut obtained was sent for histopathologic examination to determine whether smooth muscles were included in the specimen. Operative data and complications were recorded, and patients were followed up through a structured pro forma protocol. An independent assessor was assigned to obtain postoperative pain scores and satisfaction scores at six-month follow-up. Patients were also administered a simple questionnaire at follow-up to assess continence functions.

RESULTS

Over a 20-month period, 88 patients were recruited. The two groups were matched for age and gender distribution. No significant difference was identified between the two groups in terms of operation time, blood loss, day of first bowel movement after surgery, and complication rates. Despite a similar parenteral and oral analgesic requirement, the stapled group had a significantly better pain score (P = 0.002); these patients also had a significantly shorter length of stay (P = 0.02), and on average resumed work nine days earlier than the group treated with the Harmonic Scalpel (6.7 vs. 15.6, P = 0.002). Although 88 percent of doughnuts obtained in the stapled group contained some smooth muscle fibers, no association was found between smooth muscle incorporation and postoperative continence function, and as a whole the continence outcomes of the stapled group were similar to those after Harmonic Scalpel hemorrhoidectomy. Finally, at six-month follow-up, patients who underwent the stapled procedure had significantly better satisfaction scores (P = 0.001).

CONCLUSION

Stapled hemorrhoidopexy is a safe and effective procedure for Grade III hemorrhoidal disease. Patients derive greater short-term benefits of reduced pain, shorter length of stay, and earlier resumption to work. Long-term follow-up is necessary to determine whether these initial results are lasting.

Novel technology and innovations in colorectal surgery: the circular stapler for treatment of hemorrhoids and fibrin glue for treatment of perianal fistulae

The introduction of new techniques and technologies in medical science is both stimulating and controversial. This article is a review of the current status of two such advances. Since its first description, the so-called "stapled hemorrhoidectomy" has been gaining increasing popularity, at first in Asia and Europe, and more recently in the United States. It is obviously a misnomer, since no excision of hemorrhoidal tissue is undertaken in this procedure. It is probably the most significant change in the surgical treatment of hemorrhoids since the introduction of conventional hemorrhoidectomy. Patients routinely experience less postoperative pain and have excellent control of symptoms, with few serious complications in most series. Despite a relatively simple operative technique, the procedure still has specific steps and features that must be followed and mastered to help insure success. The use of fibrin glue for treatment of perianal fistulae has also been a controversial issue, thus it is seldom included in any algorithm as a therapeutic step for fistula-in-ano. The reported success rates of the treatment range from 0% to 100% owing to the heterogeneity of the clinical trials, treatment protocols, patients, etiologies, and types of fistulae. However, the benign nature, simplicity, negligible morbidity, and repeatability of the treatment, potentially makes fibrin glue an attractive first line treatment for perianal fistulae.

Nerve stimulator guided pudendal nerve block decreases posthemorrhoidectomy pain

PURPOSE

Based on our institution's initial results that reflected reduced postoperative pain using a modified pudendal nerve block technique, we conducted a prospective, randomized, double-blind study to investigate whether a combination of general anesthesia and bilateral nerve stimulator guided pudendal nerve blocks could provide better postoperative pain relief compared to general anesthesia alone or in combination with placebo nerve blocks.

METHODS

Following Ethical Committee approval and informed consent 90 patients scheduled for hemorrhoidectomy were randomized to three different groups of 30 patients each: general anesthesia alone, general anesthesia plus nerve stimulator guided pudendal nerve block or general anesthesia plus placebo nerve blocks. Postoperative pain, the primary outcome variable of the study, was assessed by visual analogue scale scores at predetermined time intervals during the postoperative period. Total amount of analgesics, time to return to normal activities and patient satisfaction were also recorded.

RESULTS

The pudendal nerve block group was found to have better postoperative pain-relief (P < 0.005), reduced need for analgesics (P < 0.05), and also a more rapid return to normal activities (P < 0.001) compared to general anesthesia alone or in combination with placebo blocks. The pudendal nerve block group was also associated with significantly higher patient satisfaction (P < 0.001) compared to the other two groups.

CONCLUSION

A combination of general anesthesia and nerve stimulator guided pudendal nerve block showed significantly reduced postoperative pain, shortened hospital stay, and earlier return to normal activity. Thus, this technique deserves more widespread use in patients undergoing hemorrhoidectomy.

Stapled hemorrhoidopexy vs. diathermy excision for fourth-degree hemorrhoids: a randomized, clinical trial and review of the literature

PURPOSE

The aim of this prospective study was to compare the results of stapled hemorrhoidopexy with those of conventional diathermy excision for controlling symptoms in patients with fourth-degree hemorrhoids.

METHODS

Thirty-one patients with symptomatic, prolapsed irreducible piles were randomized to either stapled hemorrhoidopexy (n = 15) or diathermy excision (n = 16). The primary outcome measure was the control of hemorrhoidal symptoms one year after operation.

RESULTS

The two procedures were comparable in terms of pain relief and disappearance of bleeding. Recurrent prolapse starting from the fourth month after operation was confirmed in 8 of 15 patients in the stapled group and in none in the diathermy excision group: two-tailed Fisher's exact test P = 0.002, RR 0.33, 95 percent confidence interval 0.19-0.59). Five of these patients responded well to a later conventional diathermy hemorrhoidectomy. Persistence of itching was reported in six patients in the stapled group and in one of the diathermy excision group (P = 0.03). On the other hand, six patients in the stapled group and none in the diathermy excision group experienced tenesmus (P = 0.007).

CONCLUSIONS

Stapled hemorrhoidopexy was not effective as a definitive cure for the symptoms of prolapse and itching in patients with fourth-degree hemorrhoids. Moreover, stapled hemorrhoidopexy induced the appearance of a new symptom, tenesmus, in 40 percent of the patients. Therefore conventional diathermy hemorrhoidectomy should continue to be recommended in patients with symptomatic, prolapsed, irreducible piles.

AMBULATORY CIRCULAR STAPLED HAEMORRHOIDECTOMY UNDER LOCAL ANAESTHESIA VERSUS CIRCULAR STAPLED HAEMORRHOIDECTOMY UNDER REGIONAL ANAESTHESIA

BACKGROUND

The usage of circular stapled haemorrhoidectomy (CSH) has increased dramatically in recent years. Hitherto this has been performed using regional or general anaesthesia. The present study assesses the feasibility of performing CSH under local anaesthesia on an ambulatory basis and its acceptance by patients.

METHODS

Sixty patients with symptomatic third or fourth degree haemorrhoids were randomized into two groups. Group A patients had CSH under regional anaesthesia (i.e spinal anaesthesia) and were discharged the next day and group B patients had CSH under local anaesthesia and were discharged on the same admission day. Both groups were assessed by visual analogue pain score. In addition, group B patients were asked questions regarding their satisfaction with the procedure.

RESULTS

No significant differences in pain score and analgesic requirement were found between the two groups of patients. All patients in group B except for one, reported that they were satisfied to highly satisfied with their procedure.

CONCLUSIONS

Circular stapled haemorrhoidectomy can be performed safely under local anaesthesia in an ambulatory care setting. The potential cost savings that may accrue would offset the cost of the stapler.

Postdefaecation pain syndrome after circular stapled anopexy is abolished by oral nifedipine

BACKGROUND

Controversy has surrounded the technique of circular stapled anopexy since an isolated report of a high incidence of persistent postdefaecation pain following the procedure. The characteristics, clinical course and management of this complication have not been described.

METHODS

Within an ongoing multicentre randomized clinical trial comparing circular stapled anopexy with closed haemorrhoidectomy, 77 patients underwent circular stapled anopexy. Follow-up was at 6, 12, 24 and 48 weeks. Patients underwent transanal ultrasonography, anal electrosensitivity testing and manometry.

RESULTS

Of the 77 patients who had circular stapled anopexy, three men reported new-onset postdefaecation pain that compromised lifestyle, including ability to return to work. All three had sphincter hypertonicity on digital and manometric examination but were refractory to topical 0.2 per cent glyceryl trinitrate ointment. The addition of oral nifedipine 20 mg twice daily did not alter anal sphincter pressures but rapidly abolished symptoms and restored quality of life.

CONCLUSION

Postdefaecation pain is a specific complication of circular stapled anopexy, affecting a small percentage of patients. Men with a high anal sphincter pressure appear to be at risk. Although the exact aetiology remains unclear, it is likely that rectal rather than anal sphincter muscle is affected. Oral nifedipine represents an effective therapy.

Proctology in day surgery: surgical technique

In 2002 the law number 112 defined in Italy the Elementary Assistance Levels (Livelli Essenziali di Assistenza--L.E.A.), which are the medical procedures provided to all Italian citizens by the National Health System (Servizio Sanitario Nazionale), for free or after payment of a small fee. Each Italian Regional Government has to define for each pathology (as already categorized in Disease Related Groups--D.R.G.) a benchmark, which is the percentage of cases of each pathology which should be treated in Day Surgery. The benchmarks are thresholds that should not be exceeded to avoid fines or other penalties to the hospital. In order to meet the objectives required by Italian law, a Day Surgery Unit must be able to perform as many operations as possible with high quality, high effectiveness, high efficiency, low costs and a low percentage of complications ("zero defect" objective). To get as close as possible to this objective it is necessary to seek the best organisation and the best surgical technique.

Ambulatory surgery in proctology

INTRODUCTION

In our institution we've had a lot of exerience in proctology. Ten years ago, we introduced one day surgery in our practice and had really good results in treating practically all patients who needed proctologic surgery.

MATERIALS, METHODS AND RESULTS

During this period of time 9.636 out of 73.235 outpatient cases were chosen for surgery. Among them, 2664 were patients with operations of perianal haematomas. We had some experiences with minor anal surgery (excisions of skin tags in 537 patients, excisions of papillas in 545 patients); patients with haemorrhoids, operated classically on Milligan-Morgan procedure (1116) or by the new PPH-- Longo procedure (270) and HAL technique (12). We also treated patients with fistulas--either with fistulotomy or excision of fistulae--and 1007patients with minor surgery. We made excisions of anorectal polyps in 265 patients, excisions of pilonidal cysts in 421 patients and treated 211 patients with anal abscesses. We had 282 patients with anal warts, 310 patients with anal fisures. In 35 patients we made some other small proctological interventions. In addition to proctology we made tension free operations of groin hernias in 627 patients, corrections of epigastric and umbillical hernias (26 patients) and corrections of stomas in 11 patients. The rest of our peogramm were small aseptic interventions (operations of fibromas, atheromas, verrucas, ganglions, lipomas etc.).

CONCLUSION

We have experienced ambulatory surgery (i.e. day surgery hospital) as an appropriate choice for treating the patients with proctologic pathology. However, it used to be the practice to treat all these patients in hospitals, where they occupied bed facilities that could be intended for other patients. To conclude, our present results have confirmed the decision for ambulatory surgery to be correct in the field of proctology.

Randomized controlled trial to compare the early and mid-term results of stapled versus open hemorrhoidectomy

BACKGROUND

The new technique of circular stapler for the treatment of hemorrhoids has shown early promise in terms of minimal or no postoperative pain, early discharge from hospital, and quick return to work. This study was designed to compare stapled technique with the well-accepted conventional Milligan Morgan hemorrhoidectomy.

METHODS

After fulfilling the selection criteria, 84 patients were randomly allocated to the stapled (n = 42) or open group (n = 42). All patients were operated on under spinal anesthesia. The 2 techniques were evaluated with respect to the operative time, pain scores, complications, day of discharge, return to work, and level of satisfaction.

RESULTS

The mean age of patients was 46.02 years (SD, 12.33) in the stapled group and 48.64 years (14.57) in the open group. Grade III or IV hemorrhoids were more common in men (ie, 80.9% and 85.7% in the stapled and open group, respectively). The mean operative time was shorter in the stapled group 24.28 minutes (4.25) versus 45.21 minutes (5.36) in the Milligan-Morgan group (P < .001). The blood loss, pain scores and requirement of analgesics was significantly less in the stapled group. Mean hospital stay was 1.24 days (0.62) and 2.76 days (1.01) (P < .001) in the stapled and open group, respectively. The patients in the stapled group returned to work or routine activities earlier (ie, within 8.12 days [2.48]) as compared with 17.62 (5.59) in the open group. Only 88.1% of patients were satisfied by the open method compared with 97.6% after the stapled technique. The median follow-up period was 11 months with a maximum follow-up of 19 months (range 2-19 months).

CONCLUSIONS

Stapled hemorrhoidectomy is a safe and effective day-care procedure for the treatment of grade III and grade IV hemorrhoids. It ensures lesser postoperative pain, early discharge, less time off work, complications similar to the open technique, and in the end a more satisfied patient with no perianal wound. However, more such randomized trials are essential to deny any long-term complication.

Pathological audit of stapled haemorhoidopexy

INTRODUCTION

Stapled haemorrhoidopexy is increasingly used for the surgical management of prolapsing haemorrhoids. Accurate placement of the staple line is essential to avoid involvement of the internal anal sphincter (IAS) and the pain sensitive squamous epithelium. The aim of this study was to correlate histology with symptomatic outcome after stapled haemorrhoidopexy.

PATIENTS AND METHODS

A single pathologist reviewed one hundred and six consecutive rectal mucosal specimens. Each specimen was assessed for the presence of columnar, transitional and squamous epithelium as well as involvement of smooth and skeletal muscle. In November 2003 all patients were sent a previously validated postal questionnaire about haemorrhoidal symptoms and a Cleveland Clinic continence scale. Symptomatic outcome was compared between patients who did or did not have squamous epithelium involvement in their pathology specimens and were analysed by Mann-Whitney U-test.

RESULTS

One hundred and six stapled haemorrhoidopexies were performed between June 2001 and September 2003. Eighty-four patients (79%) returned the questionnaire; 19 patients had squamous epithelium present in the pathology specimens. There was no significant difference between symptom or Cleveland Clinic scores in patients with or without squamous epithelium in their pathology specimens. Some specimens (n = 6) were found to have smooth muscle underlying squamous epithelium; this was interpreted as the presence of internal anal sphincter (IAS) within the specimen. There was no significant difference in Cleveland Clinic scores between this group and those without IAS involvement.

CONCLUSION

This study has not demonstrated a long-term difference in symptomatic outcome or continence in patients who have squamous epithelium present in their stapled haemorrhoidopexy specimens.

A double-blind, randomized trial comparing Ligasure and Harmonic Scalpel hemorrhoidectomy

PURPOSE

The major problem after hemorrhoidectomy is postoperative pain. New techniques have been evolved to circumvent this problem. The present study was conducted to compare the outcomes of Ligasure hemorrhoidectomy and Harmonic Scalpel hemorrhoidectomy.

METHODS

This study was a double-blind, randomized controlled trial. Patients with Grade 3 and 4 hemorrhoids admitted for hemorrhoidectomy were selected and randomized into two groups: 1) Ligasure hemorrhoidectomy or 2) Harmonic Scalpel hemorrhoidectomy. The primary outcomes measured were the analgesic requirement and the postoperative pain score (assessed by an independent assessor). Secondary outcome criteria included the operating time, blood loss, hospital stay, patient satisfaction score, and early and late complications.

RESULTS

Forty-nine patients were randomized into two groups (LigaSure 24, Harmonic Scalpel 25). Two patients were lost to follow-up, leaving 47 patients (LigaSure 24, Harmonic Scalpel 23) available for final analysis. The age and gender distribution were comparable. The postoperative pain score (median 2.6 vs. 4.8, P < 0.001) and postoperative oral analgesic (Dologesic) requirement (median 5 vs. 13, P = 0.001) were significantly less in the LigaSure group. The operating time (median 11 vs. 18 minutes, P < 0.001) was significantly less in the LigaSure group. The hospital stay, patient satisfaction score, percentage of patients requiring pethidine injection, percentage of patients with first bowel movement on or before the first postoperative day, and complication rates were similar between the two groups.

CONCLUSIONS

Ligasure hemorrhoidectomy reduces the postoperative pain and operating time compared to the Harmonic Scalpel hemorrhoidectomy. It is a safe, effective procedure for treating Grade 3 and 4 hemorrhoids.

Complications après anopexie circulaire pour cure d’hémorroïdes : résultats à long terme d’une série de 140 malades et analyse de la littérature

AIM

The aim of this study was to determine the results and the complications of the treatment of hemorrhoids with circular stapler with a follow-up of 18 months, and to review the complications in the literature.

METHODS

From April 1998 to August 1999, 140 patients (83 males and 57 females) with an average age of 43.8 years (range: 19-83 years) underwent haemorrhoidectomy using a circular stapler in three university hospital centers. The degree of hemorrhoids has been classified: three cases of degree II, 97 cases of degree III, and 40 cases of degree IV. All the patients were prospectively evaluated at two weeks, two and 18 months after surgery.

RESULTS

The average length of the operation was 18 minutes (range: 8-60 minutes). Mean hospital stay was 36 hours (range: 8-72 hours). There was no intraoperative complication. There was no mortality. The postoperative complication rate was 7.8% (N = 11): there were five cases of bleeding that two complicated by a submucosal hematoma (one was infected and needed a rectotomy on day 21), two cases of urinary retention, and two cases of external hemorrhoid thrombosis. The bleeding occurred in the 12 hours after surgery except for one patient with antivitamin K whith presented a secondary bleeding on day 16. At 18 months, five patients presented a moderate asymptomatic stricture dilated on digital examination. Two patients complained of persistent skin tags. Neither functional trouble nor incontinence to gas, liquids, or solids was presented. With a mean follow-up of 40 months, 90% (N = 112) of the patients were fully satisfied.

CONCLUSIONS

Treatment of hemorrhoids with circular stapler appears to be effective with 96% of patients fully satisfied at 18 months. The morbidity rate was low, and no higher than the diathermy excision hemorrhoidectomy. The results are directly dependent on the practice that required a learning, and not on the technique itself.

A prospective, randomized, controlled multicenter trial comparing stapled hemorrhoidopexy and Ferguson hemorrhoidectomy: perioperative and one-year results

PURPOSE

There is a growing body of evidence supporting the lesser degrees of pain with stapled hemorrhoidopexy, also called the procedure for prolapse and hemorrhoids. However, there have been few randomized comparisons assessing both perioperative and long-term outcomes of the procedure for prolapse and hemorrhoids and Ferguson hemorrhoidectomy. Results are presented here from the first prospective, randomized, multicenter trial comparing these hemorrhoid procedures in the United States.

METHODS

Patients with prolapsing hemorrhoids (Grade III) were randomized to undergo the procedure for prolapse and hemorrhoids or Ferguson hemorrhoidectomy by colorectal surgeons who had training in using the stapling technique. Primary end points were acute postoperative pain, and hemorrhoid symptom recurrence requiring additional treatment at one-year follow-up from surgery.

RESULTS

A total of 156 patients (procedure for prolapse and hemorrhoids, 77; Ferguson, 79) completed randomization and the surgical procedure, 18 (procedure for prolapse and hemorrhoids, 12; Ferguson, 6) had significant protocol violations. One hundred seventeen patients (procedure for prolapse and hemorrhoids, 59; Ferguson, 58) returned for one-year follow-up. Demographic parameters, hemorrhoid symptoms, preoperative pain scores, and bowel habits were similar between groups. There were a similar number of patients with adverse events in each group (procedure for prolapse and hemorrhoids, 28 (36.4 percent) vs. Ferguson, 38 (48.1 percent); P = 0.138). Reoperation for an adverse effect was required in six (7.6 percent) Ferguson patients and in 0 patients having the procedure for prolapse and hemorrhoids (P = 0.028). Postoperative pain during the first 14 days, pain at first bowel movement, and need for postoperative analgesics were significantly less in the procedure for prolapse and hemorrhoids group. Control of hemorrhoid symptoms was similar between groups; however, significantly fewer patients having the procedure for prolapse and hemorrhoids required additional anorectal procedures during one-year follow-up (procedure for prolapse and hemorrhoids, 2 (2.6 percent), vs. Ferguson, 11 (13.9 percent); P = 0.01). Only four of the Ferguson patients (5 interventions) required additional procedures more than 30 days after surgery.

CONCLUSIONS

These data demonstrate that stapled hemorrhoidopexy offers the benefits of less postoperative pain, less requirement for analgesics, and less pain at first bowel movement, while providing similar control of symptoms and need for additional hemorrhoid treatment at one-year follow-up from surgery.

Stapled hemorrhoidopexy compared with conventional hemorrhoidectomy: systematic review of randomized, controlled trials

PURPOSE

This study was designed to determine whether conventional hemorrhoidectomy or stapled hemorrhoidopexy is superior for the management of hemorrhoids.

METHODS

A systematic review of all randomized trials comparing conventional hemorrhoidectomy with stapled hemorrhoidopexy was performed. MEDLINE, EMBASE, and Cochrane Library databases were searched using the terms "hemorrhoid*" or "haemorrhoid*" and "stapl*." A list of clinical outcomes was extracted. Meta-analysis was calculated if possible.

RESULTS

Fifteen trials recruiting 1,077 patients were included. Follow-up ranged from 6 weeks to 37 months. Qualitative analysis showed that stapled hemorrhoidopexy is less painful compared with hemorrhoidectomy. Stapled hemorrhoidopexy has a shorter inpatient stay (weighted mean difference, -1.02 days; 95 percent confidence interval, -1.47 to -0.57; P = 0.0001), operative time (weighted mean difference, -12.82 minutes; 95 percent confidence interval, -22.61 to -3.04; P = 0.01), and return to normal activity (standardized mean difference, -4.03 days; 95 percent confidence interval, -6.95 to -1.10; P = 0.007). Studies in a day-case setting do not prove that stapled hemorrhoidopexy is more feasible than conventional hemorrhoidectomy. Stapled hemorrhoidopexy has a higher recurrence rate (odds ratio, 3.64; 95 percent confidence interval, 1.40-9.47; P = 0.008) at a minimum follow-up of six months.

CONCLUSIONS

Although stapled hemorrhoidopexy is widely used, the data available on long-term outcomes is limited. The variability in case selection and reported end points are difficulties in interpreting results. Stapled hemorrhoidopexy has unique potential complications and is a less effective cure compared with hemorrhoidectomy. With this understanding, it may be offered to patients seeking a less painful alternative to conventional surgery. Hemorrhoidectomy remains the "gold standard" of treatment.

Early rectal stenosis following stapled rectal mucosectomy for hemorrhoids

Background

Within the last years, stapled rectal mucosectomy (SRM) has become a widely accepted procedure for second and third degree hemorrhoids. One of the delayed complications is a stenosis of the lower rectum. In order to evaluate the specific problem of rectal stenosis following SRM we reviewed our data with special respect to potential predictive factors or stenotic events.

Methods

A retrospective analysis of 419 consecutive patients, which underwent SRM from December 1998 to August 2003 was performed. Only patients with at least one follow-up check were evaluated, thus the analysis includes 289 patients with a mean follow-up of 281 days (±18 days).

For statistic 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 9 patients (3.1%), eight of these stenoses were detected within the first 100 days after surgery; the median time to stenosis was 95 days. Only one patient had a rectal stenosis after more than one year. 8 of the 9 patients had no obstructive symptoms, however the remaining patients complained of obstructive defecation and underwent surgery for transanal strictureplasty with electrocautery. A statistical analysis revealed that patients with stenosis had significantly more often prior treatment for hemorrhoids (p < 0.01). According to the SRM only severe postoperative pain was significantly associated with stenoses (p < 0.01). Other factors, such as gender (p = 0.11), surgical technique (p = 0.25), revision (p = 0.79) or histological evidence of squamous skin (p = 0.69) showed no significance.

Conclusion

Rectal stenosis is an uncommon event after SRM. Early stenosis will occur within the first three months after surgery. The majority of the stenoses are without clinical relevance. Only one of nine patients had to undergo surgery for a relevant stenosis. The predictive factor for stenosis in the patient-characteristics is previous interventions for hemorrhoids, severe postoperative pain might also predict rectal stenosis.

Stapled hemorrhoidopexy: the argument for usage

Stapled hemorrhoidopexy is a new procedure for the treatment of symptomatic internal hemorrhoids. Experience and prospective trials are helping to define this procedure's role. Published data confirm that stapled hemorrhoidopexy offers similar control of symptoms with the benefits of reduced postoperative pain when compared with excisional techniques. Reduction in pain is the most significant benefit of this operation. Clearly, the cost of the stapling device exceeds the cost of the sutures required to perform an excisional hemorrhoidectomy. Patients should undergo medical therapy and rubber band ligation first; however, patients being considered for excisional hemorrhoidectomy should be offered stapled hemorrhoidectomy as a less painful alternative.

The "winged" circular anal dilator in stapled hemorrhoidectomy

Stapled hemorrhoidectomy is gaining popularity worldwide. One problem that is often encountered is difficulty with insertion of the circular anal dilator because of very protuberant and fatty buttocks and a narrow interischial tuberosity distance. We describe a modification of this device for easier introduction in such patients.

The use of Ligasure haemorrhoidectomy in patients taking oral anticoagulation therapy

OBJECTIVES

To assess the safety of Ligasure haemorrhoidectomy in treating patients on long-term anticoagulation therapy.

METHOD

Three patients taking warfarin underwent Ligasure haemorrhoidectomy for prolapsing haemorrhoids.

RESULTS

Each had a successful procedure without complications.

CONCLUSION

Ligasure haemorrhoidectomy can be safely performed in anticoagulated patients and reduces in-patient hospital stay.

Endoglin (CD105) expression in the development of haemorrhoids

BACKGROUND

Conventional pathogenesis of haemorrhoid emphasized the anchoring connective tissue system, whereas the vascular changes were ignored. The aim of this study was to clarify vascular changes of haemorrhoid disease.

MATERIALS AND METHODS

Forty-six samples of grade III and grade IV haemorrhoid tissue were selected for an in vitro study. We assessed the expressions in endoglin (CD105), an accessory protein in transforming growth factor-beta receptor complex, in CD34 and in vascular endothelial growth factor by using an immunohistochemical method. Microvascular density was calculated to correlate the expression of endoglin.

RESULTS

Microvascular density was higher in haemorrhoid tissue than in normal anal and lower rectal tissues. CD34 was demonstrated in whole vessels in the haemorrhoids. However, endoglin, a proliferative marker of neovascularization, was present in only 25 of 46 (54%) haemorrhoidal vessels, and its immunoactivity was prominent in venules larger than 100 micro m. Thrombosis formation and stromal vascular endothelial growth factor was significantly associated with the presence of endoglin immunoactivity.

CONCLUSION

The results of this study suggest that neovascularization is one important phenomenon of haemorrhoid disease, along with conventional venous dilatation and arteriovenous communication. In addition, thrombosis and stromal vascular endothelial growth factor might be important factors in promoting vascular proliferation.

Can the procedure for prolapsing hemorrhoids (PPH) be done twice? Results of a porcine model

BACKGROUND

The procedure for prolapsing hemorrhoids (PPH) is a new surgical method for the treatment of symptomatic hemorrhoids. In cases of recurrent prolapse, the performance of a second PPH may result in a ring of mucosa and submucosa between the two circular staple lines. In this study, we used a porcine model to assess whether PPH can be safely performed twice.

METHODS

Five adult pigs underwent two PPH procedures in one session, leaving a ring of approximately 1 cm of mucosa between the two staple lines. One month later, the pigs were examined under anesthesia. The anal canal was assessed using the following four methods: (a) clinical examination, (b) evaluation of mucosal blood perfusion at different levels of the anal canal via a laser Doppler flow detector, (c) measurement of concentrations of hydroxyproline and collagen to check for fibrosis, and (d) histopathological examination.

RESULTS

At the completion of the study period, all five pigs showed no clinical evidence of anorectal dysfunction. On examination under anesthesia 1 month after surgery, there was no evidence of anal stenosis in any of the pigs. The mean mucosal blood flow between the two staple lines did not differ significantly from the flow measured proximally and distally (394 vs 363 and 339 flow units, respectively; p = NS). The collagen levels, based on hydroxyproline concentration, were 81 mcg/mg between the staple lines, compared to 82 and 79 proximally and distally, respectively ( p = NS). There was no significant difference in degree of fibrosis, as assessed histopathologically, between specimens taken from the ring between the staple lines and specimens taken from the area external to the staple lines.

CONCLUSIONS

The results of this porcine model suggest that a second synchronous PPH is feasible. A controlled experience involving human subjects is required to determine the safety and usefulness of this technique in cases of metachronous application for recurrent or residual hemorrhoids.