[Fournier gangrene as a rare complication after stapler hemorrhoidectomy. Case report and review of the literature]

Comparison between stapled hemorrhoidopexy and harmonic scalpel hemorrhoidectomy in the management of third- and fourth-degree piles: a randomized clinical trial

BACKGROUND

This study compared the results of stapled hemorrhoidopexy (SH) and harmonic scalpel hemorrhoidectomy (HSH) in the management of grade III and grade IV piles regarding the time of the procedure, postoperative pain, patient satisfaction, wound infection, bleeding, incontinence, and recurrence within 1 year.

PATIENTS AND METHODS

This was a single-blind, prospective, randomized, controlled, single-center trial conducted from January to December 2022 that included 50 (68.75%) male and 20 (31.25%) female patients with third- and fourth-degree piles.

RESULTS

The patients were divided into two groups of 35 patients each. Group I underwent SH and group II underwent HSH. The mean age of group I was 42.94 years and of group II, 42.20 years. The mean time of the procedure was 24.42 min ± 2.367 for SH and 31.48 min ± 2.21 for HSH. Postoperative pain in group I was lower than in group II during the first 2 weeks, but there was persistent mild pain in most patients in group I at the 2‑week follow-up. In group II there was significant improvement in pain after 2 weeks, with higher patient satisfaction. Wound infection was detected in 3 (5%) patients in group I and no patients in group II (p = 0.077). Postoperative bleeding occurred in 4 (11.4%) patients in group I in the form of spotting after defecation only during the first postoperative month; no bleeding was detected in group II (p = 0.039). There were 3 (15%) cases of flatus incontinence but after taking a detailed history these were found to be cases of urgency to defecate rather than incontinence. There were 7 (20%) cases of recurrence at the 1‑year follow-up in group I and 1 (2.9%) case in group II (p = 0.024).

CONCLUSION

Compared with SH, HSH was safer, easier, and associated with a lower incidence of recurrence after 1 year and with higher patient satisfaction.

Pneumoretroperitoneum after a STARR Procedure Performed One Year after a Posterior Colporrhaphy: A Case Report and Review of the Literature

Transanal rectal resection with a stapling instrument (STARR) has been shown to be effective and safe for the treatment of obstructed defecation syndrome (ODS). Nevertheless, the wide range of complications described in the literature necessitates a rigorous patient selection and a tailored approach for the management of complications. We present here a case of pneumoretroperitoneum which occurred after a STARR procedure for ODS was performed nearly a year after previous anterior and posterior colporrhaphy. The diagnostic workup did not reveal a staple-line defect. Laparoscopy did not show any intra-abdominal pathology. The symptoms resolved under oral antibiotics. The patient was discharged on day 10 after admission. Scarring in the rectovaginal septum from a colporrhaphy 1 year earlier might have contributed to a suboptimal staple-line closure during the STARR procedure, leading to a pneumoretroperitoneum. We discuss this complication and provide a brief review of the literature.

Evaluation of the effectiveness and patients' contentment with transanal haemorrhoidal artery dearterialisation and mucopexy (THD) for treatment of haemorrhoidal disease: a 6-year study

INTRODUCTION

With high incidence of haemorrhoidal disease and significant complication rates of traditional haemorrhoidectomy procedures, transanal haemorrhoidal artery ligation and mucopexy (THD) emerges as a minimally invasive procedure with superior results. However, it is crucial that effectiveness of results and patient satisfaction be gauged based on post-operative experience, symptomology and recurrence.

AIM

Our aim is to provide a long-term analysis of efficacy and patient's satisfaction for the procedure, for the largest patient population, in correlation to presenting symptoms and degree of haemorrhoids.

METHOD

A prospective study was conducted for all the patients (324) that underwent THD between 2011 and 2016 in Naas General Hospital. The assessment was done for postoperative complications, symptoms pre- and postoperatively and patients' satisfaction rating. Clinical follow-up was done after 6 weeks and long-term follow-up by standardized questionnaire filled by telephonic clinic.

RESULTS

Of the 324 patients who underwent surgery, 256 (79.0%) participated in the study. There were 119 (46.5%) males and 137 (53.5%) females. The average age of patients was 48.40 years (17-82). Two hundred and fifteen (84.0%) patients had no recurrence. Forty-one (16.0%) had recurrence requiring further treatment. There was statistically significant higher recurrence in patients with grade 3 and 4 haemorrhoids and per-rectal bleeding (p < 0.05) while there was no statistically significant recurrence for age, gender, sedentary lifestyle and constipation/pruritus. Two hundred and twenty-four (87.5%) patients were completely satisfied from the procedure and highly recommend the procedure.

CONCLUSION

THD is a comparably pain-free procedure with improved results that prides in higher long-term satisfaction, minimal recurrence and fewer complications, in comparison to other surgical modalities.

Laparoscopic approach in a case of retroperitoneal and mesorectal haematoma following STARR procedure

INTRODUCTION

Stapled transanal rectal resection (STARR) is a widely accepted procedure for treatment of obstructed defecation syndrome.

PRESENTATION OF CASE

We analyzed major bleeding following STARR and exposed our experience regarding its conservative management with particular attention about diagnostic and therapeutic aspects.

DISCUSSION

A case by case discussion should be carried out and treatments should be driven by the features and the progression of the haematoma with regards to size, inflammatory signs or severe rectal obstruction.

CONCLUSION

If a second surgical time and exploration is considered, laparoscopy should be an effective choice while laparotomy, stoma or rectal resection should be considered in those cases with strong suspicious of peritonitis and pelvic abscess.

Short- and long-term results of harmonic scalpel hemorrhoidectomy versus stapler hemorrhoidopexy in treatment of hemorrhoidal disease

PURPOSE

In this prospective randomized study, our aim is to compare the short- and long-term results of harmonic scalpel hemorrhoidectomy (HSH) and stapler hemorrhoidopexy (SH) methods in the surgical treatment of Grade III and Grade IV hemorrhoidal disease.

METHODS

Ninety-nine consecutive patients diagnosed with Grade III or Grade IV internal hemorrhoidal disease were included in the study. Patients were randomized to HSH (n = 48) or SH (n = 51) treatments. Data on patient demographic and clinical characteristics, operative details, postoperative pain score on a visual analog scale, additional analgesic requirement, postoperative short- and long-term complications, and recurrence of hemorrhoidal disease were also recorded. Patients were regularly followed for a total period of 24 (6-36) months.

RESULTS

The patient demographic and clinical characteristics were similar in the two groups. The operative time was significantly shorter in the HSH group compared with the SH group. Overall pain scores were not significantly different between the groups, although severe pain was significantly more common in the HSH group. Recurrence was significantly lower in the HSH group compared with the SH group.

CONCLUSION

HSH and SH are both safe and effective methods for surgical treatment of Grade III and Grade IV hemorrhoidal disease. In our study, the HSH method was determined to be safer, easier, and faster to perform, and associated with fewer long-term recurrences than the SH method.

The development of Fournier's gangrene following rubber band ligation of haemorrhoids

The development of Fournier's gangrene in an 80-year-old male patient with diabetes after a routine outpatient haemorrhoid banding procedure is described. Four days following the procedure, the patient noticed an increasing amount of pain and swelling of the perianal region. When the patient presented to the emergency department 18 days later, immediate radical debridement of ischiorectal necrotic tissue was performed. A defunctioning loop sigmoid colostomy was also formed. Subsequent operations required excision of the scrotum and abdominoperineal excision of the rectum. Histology studies later confirmed the presence of necrotising fasciitis. The case acts as a reminder that clinicians should maintain a high index of suspicion for high-risk patients still suffering from problems following the procedure.

A case of Fournier's gangrene after hydrocelectomy

An uncommon case of Fournier's gangrene following hydrocelectomy is described. A 78-year-old male with no remarkable previous history, who underwent hydrocelectomy in another hospital, developed Fournier's gangrene 15 days later. The patient required wide aggressive surgical debridement, hyperbaric oxygen chamber and broad-spectrum antibiotic coverage. Afterwards the patient was referred for plastic surgery. Fournier's gangrene is a polymicrobial infection of perineoscrotal region that manifests as a rapidly progressive necrotizing fasciitis. Fournier's gangrene following hydrocelectomy is uncommon. The morbidity and mortality in this severe complication depend on early diagnosis and aggressive surgical management.

Rectal perforation with life-threatening peritonitis following stapled haemorrhoidopexy

BACKGROUND

Stapled haemorrhoidopexy is a well recognized alternative to haemorrhoidectomy, and is associated with reduced pain and earlier return to normal activity. This paper reports all published cases of life-threatening sepsis following stapled haemorrhoidopexy, identifies causative factors and makes recommendations.

METHODS

A systematic review of the literature was performed by searching the major electronic databases. All relevant references were reviewed for possible inclusion. All references of the relevant articles were screened for any further articles that were not identified in the initial search.

RESULTS

From 2000 to the present, 29 articles reporting complications in 40 patients were identified. Thirty-five patients underwent laparotomy with faecal diversion and a further patient was treated by low anterior resection. A specific complication was rectal perforation with peritonitis. Factors that led to life-threatening sepsis were identified in 30 patients. Despite surgical treatment and resuscitation, there were four deaths.

CONCLUSION

Severe sepsis can complicate stapled haemorrhoidopexy. Rectal perforation and peritonitis are a particular risk of this technique and the associated mortality rate is high.

Serious unconventional complications of surgery with stapler for haemorrhoidal prolapse and obstructed defaecation because of rectocoele and rectal intussusception

AIM

Treatment of haemorrhoidal prolapse by stapled haemorrhoidopexy (SH) and obstructed defaecation syndrome with the stapled transanal rectal resection (STARR) technique is becoming increasingly popular with patients and surgeons. Unfortunately, serious complications have been identified. The aim of the present study was to analyse the complications and their treatment to see where they might be avoided and to determine best management.

METHOD

All Units of Coloproctology belonging to the Italian Unitary Society of Coloproctology (SIUCP) were asked to return documentation of serious complications following SH and STARR.

RESULTS

Forty-six reports were received from 23 centres. Twenty-seven serious complications were reported. Twenty occurred after SH (13 PPH 03, 7 PPH 01) (Endo-surgery Inc., Cincinnati, Ohio, USA) and seven after STARR. Complications were treated by abdominal operation in nine patients [colostomy (3), ileostomy (2), Hartmann's resection (1) and anterior resection (1)].

CONCLUSION

Stapled haemorrhoidopexy and STARR can result in serious complications requiring major surgery for their treatment.

Fulminant intra-abdominal sepsis after stapled hemorrhoidectomy

BACKGROUND

Stapled hemorrhoidectomy (SH) is a modern approach for the management of hemorrhoids that can provoke life-threatening complications such as fulminant sepsis.

METHODS

Case report and review of the pertinent English-language literature.

RESULTS

A 23-year old man being treated with SH for third-degree hemorrhoids developed fulminant intra-abdominal sepsis as the result of a rectal injury during the operation. An exploratory laparotomy was performed. The rectal injury was sutured, and a temporary sigmoid loop colostomy was constructed.

CONCLUSIONS

Anorectal injury during SH can provoke serious sepsis, which the surgeon must confront promptly and aggressively.

[Rectal pocket syndrome after stapled haemorrhoidopexy]

We report the case of a 41-year-old female patient who presented in the emergency department with recurrent pain in the lower abdomen 3 years after haemorrhoidopexy (Longo's procedure). At clinical examination a space-occupying mass between the rectum and the vagina was present which was identified as a stool-loaded diverticulum of the rectum by magnetic resonance imaging. Using a perineal approach the diverticulum could be excised at its base and the defect of the mucosa was closed transanally with sutures. A diverticulum of the rectum is a rare complication (2.5%) after stapled haemorrhoidopexy. In the diagnostic of complications after Longo's haemorroidopexy the MRI constitutes an excellent auxiliary modality.

Fournier's Gangrene after Open Hemorrhoidectomy without a Predisposing Factor: Report of a Case and Review of the Literature

Fournier's gangrene (FG) is a fatal synergistic infectious disease with necrotizing fasciitis of the perineum and abdominal wall along with the scrotum and penis in men and vulva in women. An unpredictable case of FG two weeks after open hemorrhoidectomy in a previously healthy 55-year-old male is described. Full-thickness patchy skin necrosis of the perianal, perineal and scrotal region associated with rectal perforation was detected on admission. Prompt radical debridement together with aggressive fluid resuscitation and broad-spectrum antibiotic administration was initiated. Because of rectal involvement, diverting sigmoid colostomy was fashioned. The patient survived after two additional local debridements. Nevertheless, loss of sphincter function due to massive muscle destruction led to permanent colostomy. Our case together with others reported in the literature illustrates that, although rare, FG after open hemorrhoidectomy represents a life-threatening complication to otherwise healthy patients. The development of fever and urinary retention should draw the attention of the surgeon, even if the presentation is delayed. The current literature only briefly mentions the potential risk of FG after such a common surgical procedure. However, devastating complications occur more often than anticipated. This disastrous complication without predisposing factor is discussed along with a literature review.

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.

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.

Life threatening sepsis and mortality following stapled hemorrhoidopexy

BACKGROUND

Stapled hemorrhoidopexy (SH) was conceived and developed in Europe. Over the past decade, there have been reports of severe, life-threatening complications and 2 deaths. These are the first such cases from the Americas including the third known mortality.

METHODS

Two case reports from US surgeons are combined with eleven reports from the medical literature (both English and non-English speaking journals) for review. Only complications which required emergency abdominal operative intervention with fecal diversion were included.

RESULTS

These 2 cases occurred early in the surgeons' experience with SH (under 10 cases). Incomplete rings (doughnuts) of excised rectal tissue were noted in both patients. There have been a total of 13 patients reported from seven countries across three continents requiring emergency abdominal exploration and fecal diversion for complications related directly to SH. The complications noted in these 13 patients include: 9 cases of perforation, 6 cases of sepsis, 2 cases each of obstruction and Fournier's gangrene, and 1 case each of rectovaginal fistula and intra-abdominal hemorrhage. Seventy per cent of patients underwent abdominal exploration within 3 days of SH, 90% within 5 days. The age range was 24 to 77 years. Two of the 3 oldest patients did not survive the complication (68 and 77 years of age). Three patients succumbed to sepsis in the immediate postoperative period: one on postoperative day 4 after SH (Germany),one on postoperative day 6 after SH (Spain) and the third on postoperative day 10 after SH (US). The 2 mortalities from Europe occurred immediately after colostomy 4 days after SH (Germany) and immediately after re-exploration 6 days after SH and 5 days after initial colostomy (Spain). There have been a few reports of successful, non-operative management in select patients. Symptoms of abdominal pain, urinary retention, and fever after SH frequently herald these severe life-threatening complications.

CONCLUSIONS

SH has resulted in potential serious morbidity and even mortality in the immediate postoperative period. As the procedure has spread in popularity around the world, so too, it appears, have these severe, life-threatening complications. These complications are often heralded by abdominal pain, urinary retention, and fever. Surgeons should be aware of all of the potential complications (and associated warning signs and symptoms) of SH.

Stapled hemorrhoidectomy versus conventional excision hemorrhoidectomy for acute hemorrhoidal crisis

We compared the safety and clinical outcomes of stapled hemorrhoidectomy and conventional excision hemorrhoidectomy in the treatment of acute hemorrhoidal crisis, and analyzed various factors associated with complications in stapled hemorrhoidectomy. Forty patients underwent stapled hemorrhoidectomy and forty underwent conventional excision hemorrhoidectomy. All had the operation under local anesthesia with conscious sedation within 24 h of admission. The length of surgery, hospital stay, disability, postoperative pain, and the use of analgesics were significantly less for patients in the stapled hemorrhoidectomy group. Stapled hemorrhoidectomy did not significantly increase the rate of complications. Five patients in the stapled group (12.5%) required further surgical intervention: three with thrombosed hemorrhoids and two with recurrent prolapse. No serious complications were reported in either group. Patient satisfaction was similar in the two groups. Increased age was identified as a factor that significantly elevated the risk of complications in the stapled group (OR, 1.06; 95% CI, 1.01-1.13). Anemia and time between the onset of prolapsed hemorrhoids and hospital admission were also risk factors for complications, although they were not significant. Stapled hemorrhoidectomy is a feasible treatment for selected patients with an acute hemorrhoidal crisis and has a similar complication rate to that of conventional excision hemorrhoidectomy. Stapled hemorrhoidectomy is superior in less-postoperative pain, shorter operation time, shorter hospital stay, and earlier return to normal activity. However, we suggest that older patients with anemia or a prolonged hemorrhoidal crisis are unsuitable for stapled hemorrhoidectomy.

Delayed presentation of life-threatening perineal sepsis following stapled haemorrhoidectomy: a case report

Fournier's gangrene has been described after injection sclerotherapy and banding of haemorrhoids as well as after conventional haemorrhoidectomy. In addition, there have been several cases following stapled haemorrhoidopexy. A patient with this complication nearly always presents within the first week following surgery. We present an illustrative case of a patient who underwent stapled haemorrhoidopexy for prolapsed haemorrhoids and presented with fever, urinary retention and peri-anal pain 39 days later. At re-operation, there was extensive peri-anal necrosis. After wide excision and fashioning of a colostomy, the patient recovered. Our case shows that late presentation can occur.

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.

Hemorrhoidopexy staple line height predicts return to work

PURPOSE

Previous studies identified reduction in pain and complications with stapled hemorrhoidopexy relative to conventional hemorrhoidectomy. Previously, the presence of resected squamous epithelium and a staple line height <20 mm above the dentate line were predictive of postoperative pain. The purpose of this study was to further investigate and refine the role of staple height in the prediction of postoperative outcomes.

METHODS

From July 2002 to October 2004, 75 patients with symptomatic Grade 3 and 4 mixed hemorrhoids underwent stapled hemorrhoidopexy in two teaching institutions with prospective data collection. All procedures were performed under the direct supervision of two colorectal teaching staff. The majority were performed under monitored anesthesia care as outpatient procedures. Preoperative, intraoperative, and postoperative patient characteristics were evaluated. This included demographics, staple line height, specimen histology, complications, days to return to work, duration of narcotic pain medicine, and preoperative/postoperative tone and seepage. The results were subjected to statistical analysis using t-test and ANOVA.

RESULTS

Seventy-five patients with a median age of 49 (range, 25-87) years were identified. Histology identified 62 specimens with columnar and/or transitional cells, 10 with squamous epithelium, and 3 with muscle present. Overall complication rate was 14 percent. Complications included three readmissions for pain control, three acute postoperative anal fissures, two postoperative bleeds (with one requiring examination under anesthesia without intervention), one patient with subcutaneous emphysema, and one admission for fecal impaction. Staple line height was not a statistically significant predictor of postoperative complication. Median return to work was 14 (range, 1-31) days. Median duration of narcotic use was six (range, 0-40) days. Patients with a staple line height>22 mm required a significantly shorter duration of narcotic pain management (P=0.024). Median follow-up was 24 (range, 9-253) days. Staple line heights below 20 mm had a mean return to work of 15 days. A staple line height>20 mm had a mean return to work of nine days. Staple line height was inversely related to return to work (P=0.01).

CONCLUSIONS

A hemorrhoidopexy staple line>or=22 mm above the dentate line correlates with a significantly shorter need for postoperative narcotics (P=0.024) and an earlier return to work (P=0.017). Staple line distance above the dentate line meaningfully impacts comfort-based outcomes.

Life-threatening sepsis following treatment for haemorrhoids: a systematic review

INTRODUCTION

Haemorrhoids are a common complaint with estimates suggesting a prevalence of 4% of the adult population. Treatments such as rubber band ligation (RBL), sclerotherapy and excisional surgery have been in use for many years, and recently stapled haemorrhoidopexy, or procedure for prolapsing haemorrhoids (PPH) has gained acceptance. However, there have been consistent reports of severe sepsis, including a number of deaths. The purpose of this review was to assess the scale of the problem, and identify any predisposing factors, common presenting features, and treatment options in those who suffer these complications.

RESULTS

Twenty-nine papers were identified, reporting 38 patients. Of these, 17 had undergone RBL, three had sclerotherapy, one had cryotherapy, 10 had excisional surgery and seven had PPH. Ten died as a result of their sepsis. The cases included 16 with perineal sepsis, seven with retroperitoneal gas and oedema, and six with liver abscesses. Common presenting features were urinary difficulties, fever, severe pain, septic shock and leucocytosis. Most were managed by means of surgery, although a minority survived having received conservative therapy. With the exception of two patients (one of whom was human immunodeficiency virus positive and the other had a drug-induced agranulocytosis) all were well prior to surgery.

CONCLUSIONS

Although extremely uncommon, severe sepsis does occur post-treatment for haemorrhoids and all surgeons who treat such patients should be aware of the potential complications and alert to their presenting features. Early presentation without evidence of tissue necrosis may be managed conservatively, although most cases are managed by means of surgery.

Complications and reoperations in stapled anopexy: learning by doing

Although stapled anopexy for second and third degree hemorrhoids has been widely used since 1998, there are limited long-term data available. We performed an analysis of a prospectively accrued data set of all patients undergoing stapled anopexy in our practice from 1998 through August 2003. Patients were specifically assessed for early and late complications and long-term reoperation rates for anorectal pathology. We performed stapled anopexy in 654 patients (296 females) during the study period. Mean operation time was 21 min (5-70 min), and the postoperative stay was 3.6 days (1-13 days). Early postoperative complications: urinary retention, 42 patients (6.4%); fecal impaction, 18 (2.8%); postoperative hemorrhage, 26 (4.0%); thrombosed external hemorrhoid, four (0.6%); and fistula/abscess, nine (1.4%). Late postoperative complications: anastomotic dehiscence, 21 patients (3.2%); persistence of prolapse in three (0.5%); submucosal anastomotic cysts in four (0.6%); thrombosed external hemorrhoid in two (0.3%); skin tags in ten (1.5%); fissure in six (0.9%); proctitis in two (0.3%); and fecal incontinence in ten (1.5%). Reoperation was required in 50 patients (7.6%). Reoperation for complications within 30 days occurred in 42 patients (6.4%) for the following reasons: bleeding (23), dehiscence (five), thrombosed external hemorrhoid (three), fecal retention (two), fistula (three), fissure (five), and anal papilla (one). Reoperation for anorectal pathology after 30 days was required in 54 patients (8.3%) and was performed for the following: dehiscence/reprolapse (17), stenosis (two), submucous cyst (two), fistula (four), fissure (six), anal papilla (four), skin tags (five), persistent anal itching (five), and miscellaneous (seven). These data represent the largest series of patients with long-term follow-up following stapled anopexy and confirm that the operation is safe in experienced hands using appropriate patient selection. The early complication rate is low and similar to rates reported for excisional hemorrhoidectomy. Importantly, the procedure is associated with a low 3.4% rate of reoperation for persistence or recurrence of hemorrhoidal prolapse with good patient selection.

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.

Fournier's gangrene after Milligan-Morgan hemorrhoidectomy requiring subsequent abdominoperineal resection of the rectum: report of a case

The development of Fournier's gangrene after Milligan-Morgan hemorrhoidectomy of a previously healthy 76-year-old female patient is described. After such a common surgical procedure, the patient developed full-thickness skin necrosis of the perianal region including the rectum. Immediate radical debridement was mandatory. Because of rectal involvement, a diverting sigmoid colostomy was required. The rectum had to be removed by abdominoperineal resection. This disastrous complication was completely unexpected and unpredictable after Milligan-Morgan hemorrhoidectomy because of the lack of predisposing factors.