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

Comparison the effect of gelatin sponge and epinephrine-soaked gauze for hemostasis and pain control after hemorrhoidal surgery

Post-operative pain and bleeding are the main complications following hemorrhoidal surgery. This study aimed to investigate whether an absorbable gelatin sponge is a superior hemostatic and analgesic agent compared to gauze soaked in epinephrine for post-hemorrhoidal surgery care. A retrospective study was conducted using data from a single institute. Data were collected from the electronic medical record database and outpatient patient questionnaire archive. The study encompassed 143 patients who received gauze soaked in epinephrine as the hemostatic agent after hemorrhoidal surgery and 148 patients who received an absorbable gelatin sponge. Most patients underwent stapled hemorrhoidopexy, with 119 (83.2%) in epinephrine group and 118 (79.7%) in gelatin sponge group. The primary outcome measurements were postoperative pain score, oral analgesic dosage and complications. Patients in the absorbable gelatin sponge group reported significantly lower pain scores from 8 h after their hemorrhoidal surgery (postoperative day 0) through postoperative day 2. The average pain scores in the absorbable gelatin sponge group and gauze soaked in epinephrine group were 5.3 ± 3.2 and 6.2 ± 3.2 (p = 0.03) on postoperative 8 h; 4.7 ± 3.0 and 5.8 ± 2.9 (p ≤ 0.01) on postoperative day one; and 4.4 ± 2.8 and 5.3 ± 2.9 (p = 0.01) on postoperative day two, respectively. There were no significant differences in postoperative recovery or complication rates between the two groups. Our study revealed that absorbable gelatin sponges provide more effective pain relief to patients during the initial postoperative days after hemorrhoidal surgery, without any adverse impact on patient outcomes. Consequently, absorbable gelatin sponges are recommended as a replacement for gauze soaked in epinephrine following hemorrhoidal surgery.

Interventional treatments for prolapsing haemorrhoids: network meta-analysis

BACKGROUND

Multiple treatments for early-moderate grade symptomatic haemorrhoids currently exist, each associated with their respective efficacy, complications, and risks. The aim of this study was to compare the relative clinical outcomes and effectiveness of interventional treatments for grade II-III haemorrhoids.

METHODS

A systematic review was conducted according to PRISMA criteria for all the RCTs published between 1980 and 2020; manuscripts were identified using the MEDLINE, Embase, and CENTRAL databases. Inclusion criteria were RCTs comparing procedural interventions for grade II-III haemorrhoids. Primary outcomes of interest were: symptom recurrence at a minimum follow-up of 6 weeks, postprocedural pain measured on a visual analogue scale (VAS) on day 1, and postprocedural complications (bleeding, urinary retention, and bowel incontinence). After bias assessment and heterogeneity analysis, a Bayesian network meta-analysis was performed.

RESULTS

Seventy-nine RCTs were identified, including 9232 patients. Fourteen different treatments were analysed in the network meta-analysis. Overall, there were 59 RCTs (73 per cent) judged as being at high risk of bias, and the greatest risk was in the domain measurement of outcome. Variable amounts of heterogeneity were detected in direct treatment comparisons, in particular for symptom recurrence and postprocedural pain. Recurrence of haemorrhoidal symptoms was reported by 54 studies, involving 7026 patients and 14 treatments. Closed haemorrhoidectomy had the lowest recurrence risk, followed by open haemorrhoidectomy, suture ligation with mucopexy, stapled haemorrhoidopexy, and Doppler-guided haemorrhoid artery ligation (DG-HAL) with mucopexy. Pain was reported in 34 studies involving 3812 patients and 11 treatments. Direct current electrotherapy, DG-HAL with mucopexy, and infrared coagulation yielded the lowest pain scores. Postprocedural bleeding was recorded in 46 studies involving 5696 patients and 14 treatments. Open haemorrhoidectomy had the greatest risk of postprocedural bleeding, followed by stapled haemorrhoidopexy and closed haemorrhoidectomy. Urinary retention was reported in 30 studies comparing 10 treatments involving 3116 participants. Open haemorrhoidectomy and stapled haemorrhoidopexy had significantly higher odds of urinary retention than rubber band ligation and DG-HAL with mucopexy. Nine studies reported bowel incontinence comparing five treatments involving 1269 participants. Open haemorrhoidectomy and stapled haemorrhoidopexy had the highest probability of bowel incontinence.

CONCLUSION

Open and closed haemorrhoidectomy, and stapled haemorrhoidopexy were associated with worse pain, and more postprocedural bleeding, urinary retention, and bowel incontinence, but had the lowest rates of symptom recurrence. The risks and benefits of each treatment should be discussed with patients before a decision is made.

Comparison of the short-term outcomes of using DST and PPH staplers in the treatment of grade III and IV hemorrhoids

Stapled hemorrhoidopexy has a few advantages such as less postoperative pain and faster recovery compared with conventional hemorrhoidectomy. There are two major devices used for stapled hemorrhoidopexy, PPH stapler (Ethicon EndoSurgery) and DST stapler (Covidien). This study was conducted to investigate the postoperative outcomes among patients with grade III and IV hemorrhoids who underwent hemorrhoidopexy with either of these two devices. A total of 242 consecutive patients underwent stapled hemorrhoidopexy with either PPH stapler (110 patients) or DST stapler (132 patients) at a single center in 2017. We performed a retrospective case–control study to compare the short-term postoperative outcomes and the complications between these two groups. After matching the cases in terms of age, gender, and the grade of hemorrhoids, there were 100 patients in each group (PPH versus DST). There were no significant differences in the postoperative visual analog scale (VAS) score and analgesic usage. Among complications, the incidence of anorectal stricture was significantly higher in the DST group (p = 0.02). Evaluation of the mucosal specimen showed that the total surface area, the muscle/mucosa ratio and the surface area of the muscle were also significantly higher in the DST group (p = 0.03). Further analysis of the DST group demonstrated that patients with anorectal stricture after surgery are younger than patients without anorectal stricture, and higher muscle/mucosa ratio (p = 0.03) and a higher surface area of the muscle (p = 0.03) also measured in the surgical specimen. The two devices provide similar outcomes of postoperative recovery. Patients who underwent DST stapled hemorrhoidopexy had a higher incidence rate of stricture, larger area of muscle excision, and higher muscle/mucosa ratio in the surgical specimen. Further investigation is warranted for a better understanding of the correlation between muscle excision and anorectal stricture.

Pre-operative assessment of internal mucosal rectal prolapse in internal hemorrhoids: technical details and results from a single institution

BACKGROUND

The aim of the study was to assess safety and efficacy of pre-operative assessment for internal mucosal rectal prolapse (IMRP) in internal hemorrhoids, in order to achieve a tailored transanal stapled surgery.

METHODS

All consecutive patients (January 2011 to December 2014; age 18-80 years), affected by prolapses with II-IV degrees hemorrhoids that underwent Longo procedure with EEA® Auto Suture stapler (Covidien) were included in the present study.

RESULTS

A total of 100 consecutive patients (38 females) were enrolled in the study. Preoperative Visual Analogue Scale pain assessment was 7.33±2.68. The mean duration of the procedure was 34.1±17.8 min, and the median hospital stay was 2 days (range 2-6). No major complication occurred, including relapses of mucosal prolapse. Preoperative prolapse measurement with EEA® EEA® Auto Suture stapler (2.3±0.5 cm) was well correlated direct assessment (2.4±0.6, p<0.001), but a proportional bias was identified, with significant preoperative underestimation of IMRP, particularly for lesions larger than 3 cm (around 10% of actual extent).

CONCLUSIONS

EEA® Auto Suture stapler seems to be safe and effective for a tailored approach to anorectal prolapse due to hemorrhoids. However, it reasonable that its actual impact may have been overestimated, beneficing of the repetitive, direct assessment of the operatory field guaranteed by preoperative IMRP measurement.

Effects of Stapled Hemorrhoidopexy on Anorectal Function: A Prospective Randomized Controlled Trial

BACKGROUND

Stapled hemorrhoidopexy is a safe and acceptable alternative to traditional hemorrhoidectomy with shorter hospital stay, better satisfaction, and less postoperative pain. There have, however, been reports on early and late complications. Therefore, the present study was designed to assess the impact of stapled hemorrhoidopexy on anorectal function and continence.

METHODS

Sixty-one patients with rectal prolapse and/or symptomatic circumferential hemorrhoidal disease, as validated by the Wexner incontinence score, were included. Anal manometric indices were measured. The Wexner scores and anal manometric measures were compared pre- and postoperatively using the Mann-Whitney U test. (A P<0.05 was considered significant.).

RESULTS

Mean age was 46.8 years (range=18-80 y), with a mean follow-up time of 3 months. Fifty-one patients completed their follow-ups. For 45 patients with a Wexner score of 0 and no history of incontinence, the anal maximum squeezing pressure (AMD) was 125.3±43.1 mm Hg, the anal resting pressure (ARD) was 27.8±12.8 mm Hg, and the mean pressure was 40.0±16.8 mm Hg. The changes in the anorectal manometric indices before and 3 months after the operation were not statistically significant (P=0.99, P=0.55, and P=0.32, respectively). In 6 patients with Wexner scores of 1 or higher, the mean values of the AMD, ARD, and mean pressure not only decreased but also increased postoperatively, but the changes were not statistically significant (P=0.32, P=0.42, and P=0.45, correspondingly).

CONCLUSION

These data represent a series of patients with 3 months' follow-up after stapled hemorrhoidopexy and suggest that this technique is safe in experienced hands. It may have protective effects on anorectal function in patients with imperfect continent scores. Trial Registration Number: IRCT2015101324504N1.

Stapled Haemorrhoidopexy versus Ferguson Haemorrhoidectomy: A Prospective Study with 2-Year Postoperative Follow-up

Patients with grade III or IV haemorrhoids underwent stapled haemorrhoidopexy or Ferguson haemorrhoidectomy (50 patients in each group) between June 2000 and April 2003. Six patients (12.0%) receiving stapled haemorrhoidopexy experienced complications: bleeding (2.0%) and haematoma (4.0%); late complications were anal fissure (4.0%) and recurrence of haemorrhoidal disease (2.0%). Bleeding was treated during the operation by suture ligation and fissures by sphincterotomy; haematomas resolved spontaneously with conservative medical treatment. Of those undergoing Ferguson haemorrhoidectomy, no bleeding occurred postoperatively, however urinary retention was seen in three patients (6.0%) We conclude that Ferguson haemorrhoidectomy was safer than stapled haemorrhoidopexy for bleeding complications, but stapled haemorrhoidopexy was superior to the Ferguson technique in terms of postoperative pain (4.2 versus 7.4 on day 1 after operation, decreasing to 2.2 versus 4.2 at 1 week for stapled haemorrhoidopexy compared with Ferguson haemorrhoidectomy, respectively), duration of hospital stay (92% undergoing stapled haemorrhoidopexy discharged on postoperative day 1) and time to return to normal activities (10.0 ± 1 versus 28.0 ± 2 days, respectively).

Systematic review and network meta-analysis comparing clinical outcomes and effectiveness of surgical treatments for haemorrhoids

BACKGROUND

The aim was to compare the clinical outcomes and effectiveness of surgical treatments for haemorrhoids.

METHODS

Randomized clinical trials were identified by means of a systematic review. A Bayesian network meta-analysis was performed using the Markov chain Monte Carlo method in WinBUGS.

RESULTS

Ninety-eight trials were included with 7827 participants and 11 surgical treatments for grade III and IV haemorrhoids. Open, closed and radiofrequency haemorrhoidectomies resulted in significantly more postoperative complications than transanal haemorrhoidal dearterialization (THD), LigaSure™ and Harmonic® haemorrhoidectomies. THD had significantly less postoperative bleeding than open and stapled procedures, and resulted in significantly fewer emergency reoperations than open, closed, stapled and LigaSure™ haemorrhoidectomies. Open and closed haemorrhoidectomies resulted in more pain on postoperative day 1 than stapled, THD, LigaSure™ and Harmonic® procedures. After stapled, LigaSure™ and Harmonic® haemorrhoidectomies patients resumed normal daily activities earlier than after open and closed procedures. THD provided the earliest time to first bowel movement. The stapled and THD groups had significantly higher haemorrhoid recurrence rates than the open, closed and LigaSure™ groups. Recurrence of haemorrhoidal symptoms was more common after stapled haemorrhoidectomy than after open and LigaSure™ operations. No significant difference was identified between treatments for anal stenosis, incontinence and perianal skin tags.

CONCLUSION

Open and closed haemorrhoidectomies resulted in more postoperative complications and slower recovery, but fewer haemorrhoid recurrences. THD and stapled haemorrhoidectomies were associated with decreased postoperative pain and faster recovery, but higher recurrence rates. The advantages and disadvantages of each surgical treatment should be discussed with the patient before surgery to allow an informed decision to be made.

[Modification to stapled mucosectomy technique with PPH. Experience of a surgical group]

BACKGROUND

Haemorrhoidal disease is a common disorder. Surgical treatment is indicated in cases of advanced disease. However, postoperative pain, operative time, and technical difficulties have prompted the search for new procedures and improve the existing ones. A modification is proposed to the technique of PPH (Procedure for Prolapse and Haemorrhoids) stapled haemorrhoidectomy that facilitates and standardises the procedure without altering its benefits.

OBJECTIVE

To describe the postoperative results and short-term evolution of patients with internal haemorrhoidal disease, who underwent stapled mucosectomy with PPH with a modified technique.

MATERIAL AND METHODS

This is a retrospective review of 35 patients who underwent stapled haemorrhoidectomy with a modified technique by the same surgical team.

RESULTS

Twenty-five patients were men (71%) and 10 women (29%). Sixteen patients had grade III internal haemorrhoid disease (46%) and 19 grade IV (54%). The mean operative time was 31 minutes. Six patients had acute urinary retention. There were no cases of severe pain, bleeding, haematoma, stenosis, incontinence, thrombosis, or re-operation. The median hospital stay was 1 day.

CONCLUSIONS

The proposed modification of PPH haemorrhoidectomy is performed with greater technical ease without increased morbidity, preserving the advantages of the original technique.

Hemorrhoidectomy - making sense of the surgical options

While debate continues as to which is the best surgical method for the treatment of hemorrhoids, none of the currently available surgical methods approach the ideal surgical option, which is one that is effective while being safe and painless. In reality, the less painful the procedure, the more likely it is to be associated with recurrence post-op. Where hemorrhoids surgery is concerned, there isn't a "one size fits all" option. Most of the randomized controlled trials performed to date include hemorrhoids of various grades and with a focus on only comparing surgical methods while failing to stratify the outcomes according to the grade of hemorrhoid. We believe that surgery needs to be tailored not only to the grade of the hemorrhoids, but also to the size, circumferential nature of the disease, and prevailing symptomatology.

Six years after: complications and long-term results after stapled hemorrhoidopexy with different devices

PURPOSE

Stapled hemorrhoidopexy (SH) was introduced in 1998. Early in the experience, a standard circular stapler was often used, while later specifically designed staplers for SH were developed. Although the diameter of the circular cutting knife differ significantly, it remains unclear, if the volume of the excised tissue differs and if this has an influence on the long-term results and complications.

METHODS

We evaluated in a prospective consecutive database that underwent SH from January 2003 through April 2004. There were three devices used during the study period: end-to-end-anastomosis (EEA) 31, stapler device for haemorrhoids (SDH) and procedure for prolapse and haemorrhoids (PPH). Procedure selection was at the discretion of the surgeon; however, the indications for surgery were similar for all involved surgeons. Demographic and operative characteristics were analysed. Follow-up data were collected continuously over the time, and in May 2010, these patients received a questionnaire. Data were compared by t test and chi-square test, respectively.

RESULTS

There were 214 (97 females) evaluable patients. Seventy-three patients were operated with EEA-31, 52 with SDH- and 89 with PPH. The median follow-up was 6.8 years and complete data were available for 131 (61.2%) patients. Demographic characteristics were comparable within the three groups. SDH (6 ml) and PPH (6.5 ml) resected significantly (p < 0.05) more tissue than EEA (5 ml). Early postoperative incontinence rate was significantly higher in the PPH group (6%) as compared to EEA (1%) and SDH (0%). The incidence of other early complications was similar across techniques. The overall complication rates and reoperation rates were similar. Although 41% of the patients had minor anorectal complaints (itching and soiling), incontinence rates were low (2-3%) without any significant differences between the devices.

CONCLUSIONS

The results of cohort of SH patients support the conclusion that short- and long-term outcomes are device independent, although each approach is associated with a modest degree of ongoing anorectal symptoms.

Haemorrhoidectomy: prevalence and risk factors of urine retention among post recipients

AIMS AND OBJECTIVES

The purpose of this study was to explore the prevalence and risk factors of urine retention among posthaemorrhoidectomy recipients. BACKGROUND. Haemorrhoids are one of the most common functional disorders of the anus. The Haemorrhoidectomy surgical procedure is one of the primary treatments for more severe haemorrhoidal occurrences, such as for third- and/or fourth-degree haemorrhoid conditions. Urine retention is a common acute complication after operation, but rare study conducted by nurses in Taiwan to explore the prevalence and risk factors.

DESIGN

A retrospective chart review was conducted.

METHODS

Data from a prospectively maintained database on patients who had undergone haemorrhoidectomy between April 2004 - August 2008 were retrospectively analysed. A total of 469 charts were used in this analysis. The following outcomes were studied: patient profiles, haemorrhoid type and severity, anaesthesia methods, length of operating room stay, urine retention and management, intravenous fluid given during operation and length of stay. Results.  The overall urinary retention rate was 32.8% (n = 153). Significant risk factors associated with postoperative urinary retention included severity of haemorrhoid and anaesthesia methods. Logistic regression analysis revealed that epidural anaesthesia (p = 0.008), spinal anaesthesia (p = 0.016) and haemorrhoids with a severity of three degrees or higher (p = 0.017) were predictors of urinary retention post haemorrhoidectomy.

CONCLUSIONS

Acute urinary retention can have an adverse effect on a patient's quality of care. Careful follow-up of patients with these risk factors can help nurses spot posthaemorrhoidectomy urinary retention early.

RELEVANCE TO CLINICAL PRACTICE

The prevalence of acute urinary retention post haemorrhoidectomy is common. Surgical ward nurses should therefore take the responsibility regarding the impact of urinary retention and seeking appropriate nursing interventions of induced urination.

Proctalgia as a late complication of stapled hemorrhoidectomy. Report of our case series

INTRODUCTION

Incidence and etiology of persistent pain after stapled hemorrhoidectomy remain uncertain. Characteristics, clinical course and management of this complication have not yet been assessed. Purpose of this essay is to describe our experience with persistent pain in our series of patients with this technique.

METHODS

This retrospective study evaluated 126 cases of stapled hemorrhoidectomy treated from 2006 to 2009. We gathered information on each patient regarding type of prolapsed hemorrhoids, number of haemostatic suture placed, histology of each doughnut and post operative complications. A close follow up was done in those patients complaining about pain.

RESULTS

Early and late complications occurred in 11.9% and 16.7% of patients respectively. At two weeks from surgery 18 patients (14.3%) were complaining of persistent pain. The average number of haemostatic sutured placed in this group and in all series is 4.5 and 2.5 respectively. Eight patients (6.34%), 3 (2.4%) and 2 (1.6%) patients were still complaining of persistent pain at 1 month, 4 months and 6 months of follow up, respectively. In these patients, endoanal manometry was normal at 4 months from surgery, while endoanal ultrasound showed retained staples in 3 of them. At 7 months from surgery a staples removal was performed in 2 patients that were still complaining of pain.

CONCLUSIONS

Incidence of pain at 2 weeks after surgery resulted in 14.3% of patients. In most patients its etiology remains unclear but we reckon it might be related to the high number of haemostatic sutures placed. Staples removal resulted successfully.

Evidence-based management of pain after haemorrhoidectomy surgery

BACKGROUND

Haemorrhoidectomy is associated with intense postoperative pain, but optimal evidence-based pain therapy has not been described. The aim of this systematic review was to evaluate the available literature on the management of pain after haemorrhoidal surgery.

METHODS

Randomized studies published in the English language from 1966 to June 2006, assessing analgesic and anaesthetic interventions in adult haemorrhoidal surgery, and reporting pain scores, were retrieved from the Embase and MEDLINE databases.

RESULTS

Of the 207 randomized studies identified, 106 met the inclusion criteria, with mixed methodological quality. Of these, 41 studies evaluating surgical and alternative interventions were excluded. Quantitative analyses were not performed, as there were limited numbers of trials with a sufficiently homogeneous design.

CONCLUSION

Local anaesthetic infiltration, either as a sole technique or as an adjunct to general or regional anaesthesia, and combinations of analgesics (non-steroidal anti-inflammatory drugs, paracetamol and opiates) are recommended. If appropriate, a stapled operation may be preferable.

LigaSure hemorrhoidectomy versus stapled hemorrhoidopexy: a prospective, randomized clinical trial

PURPOSE

This study was designed to compare the outcome of LigaSure hemorrhoidectomy and stapled hemorrhoidopexy for prolapsed hemorrhoids.

METHODS

Consecutive patients with grade III or IV hemorrhoids were randomly assigned to undergo either LigaSure hemorrhoidectomy or stapled hemorrhoidopexy. Data on patient demographic and clinical characteristics, operative details, postoperative pain score on a visual analog scale, number of parenteral analgesic injections, duration of hospital stay, and time to return to work were all prospectively collected. Postoperative complications and recurrence of prolapse were also recorded. Patients were regularly followed for a total period of 12 months.

RESULTS

A total of 68 patients completed the study (34 per group). Patient demographic and clinical characteristics were similar in the 2 groups. No significant differences between LigaSure hemorrhoidectomy and stapled hemorrhoidopexy were observed in mean operating time, postoperative pain score, number of parenteral analgesic injections, duration of hospital stay, or time to return to work. The groups were also similar regarding postoperative complications, except that at 4 weeks postoperatively, residual prolapse was observed in 8 patients (23.5%) in the stapled hemorrhoidopexy group vs. 2 patients (5.9%) in the LigaSure group (P = .040). Rate of recurrence of prolapse at 1 year was higher with stapled hemorrhoidopexy (4 patients, 11.8%) than with the LigaSure procedure (1 patient, 2.9%), but the difference was not significant (P = .163).

CONCLUSIONS

LigaSure hemorrhoidectomy and stapled hemorrhoidopexy yield comparable good results, with a short operative time and minimal side effects in the treatment of grade III and IV hemorrhoids, but with a lower rate of residual prolapse for the LigaSure procedure. Both procedures offer low levels of postoperative pain and therefore are excellent therapeutic options for prolapsed grade III and IV hemorrhoids. A larger controlled study is needed to reach solid conclusions regarding risk of postoperative recurrence of hemorrhoidal prolapse.

Complications, recurrences, early and late reoperations after stapled haemorrhoidopexy: lessons learned from 1,233 cases

PURPOSE

The purpose of the study was to analyse the outcomes of all patients requiring a reoperation after an initial circular stapled haemorrhoidopexy (SH) for prolapsing haemorrhoids.

METHODS

Data of all patients undergoing a circular SH from 1998 thru 2007 available in a prospectively collected database were reviewed, and all patients who had reoperations were studied.

RESULTS

During the study period, 1,233 patients (551 females, median age 52 years) underwent a circular SH. Complete follow-up was available in all patients (median follow-up 7 months, range 0.5-100); 127 patients (10.3%) required one or more reoperations. Early reoperations (<30 days) were necessary in 47 patients (3.8%), and 45 (3.6%) were stapler-related complications. Late reoperations (>30 days) were performed in 84 patients (6.8%) and 57 (4.6%) were stapler-related. A learning curve was observed with significant reduction of early (<30 days) and late (>30 days) reoperation rate with time.

CONCLUSIONS

Reoperations after SH are necessary in about 10% of the patients. The majority of the reoperations are due to either complications arising from circular SH, recurrent/persistent haemorrhoidal symptoms or other anorectal issues not addressed by the circular SH procedure (3.8% early; 6.8% late). Circular SH appears to be an effective procedure for symptomatic haemorrhoidal disease; however, training and learning curve issues should be addressed to minimise treatment failures.

Intraoperative ligation of residual haemorrhoids after stapled mucosectomy

BACKGROUND

High recurrence rates are being reported with stapled mucosectomy (SM) in patients with high-grade haemorrhoids. A modification was at--tempted in which SM was followed by ligation and cutting of residual prolapsing haemorrhoids, and the procedure was compared with standard SM.

METHODS

The study included 45 patients with high-grade haemorrhoids (grades 3 and 4), who underwent SM. The patients were divided into an SM(std) group (SM by the standard procedure) and an SM(mod) group (SM by the modified procedure).

RESULTS

There were 21 patients in the SM(std) group and 19 patients in the SM(mod) group. Five patients were lost to follow-up. The mean age, hospital stay, number of painful days during the postoperative period and the number of days before resumption of normal work were not significantly different between the groups (p>0.05). Recurrence rates were significantly lower in the SM(mod) group (2/19, 10.5%) than in the SM(std) group (14/21, 66.7%; p=0.0004). The percentage of patients highly satisfied (score -1) with the procedure was significantly higher in the SM(mod) group (73.7%, 14/19) than in the SM(std) group (33.3%, 7/21; p=0.014).

CONCLUSION

Patients with high-grade haemorrhoids in whom a modified stapled mucosectomy (ligating and cutting the residual haemorrhoids on the operating table after the procedure) was performed had a significantly lower recurrence rate and better satisfaction rate than patients in whom standard stapled mucosectomy was performed. Long-term studies in a larger group of patients are needed to substantiate these results.

Stapled versus Ferguson hemorrhoidectomy: is there any evidence-based information?

AIMS

The objective of this study was to compare the perioperative, short-term, and long-term outcomes of stapled hemorrhoidectomy with Ferguson hemorrhoidectomy.

MATERIALS AND METHODS

The present meta-analysis pooled the effects of outcomes of a total 926 patients treated with stapled or Ferguson hemorrhoidectomy in five out of 122 screened for retrieval randomized controlled trials using the fixed-effects or a random-effects model.

RESULTS

Stapled hemorroidectomy was equivalent to the Ferguson procedure in comparisons pertaining to the following outcomes: hospital stay, postoperative hemorrhage requiring intervention, early postoperative bleeding <4 weeks, late postoperative bleeding <8 weeks, and the presence of anal pathology at 1 year follow-up. Stapled hemorrhoidectomy was superior with impact to operative time, pain visual analogue scale score at 24 h, urinary retention, and wound healing.

CONCLUSIONS

There is convincingly apparent evidence about the safety and efficacy of stapled hemorrhoidectomy in the comparison with the well-established Ferguson procedure.

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.

Stapled versus conventional surgery for hemorrhoids

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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