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

Association of Muscle Fibers with Histopathology in Doughnut Specimens Following Stapled Hemorrhoidopexy and Their Impacts on Postoperative Outcomes

Background Stapled hemorrhoidopexy is widely practiced worldwide since its introduction to the world of proctology and replaced conventional hemorrhoidectomy in treating hemorrhoids. The technique of executing the procedure dictates the outcomes and complications. Here, we attempted to establish the cause of postoperative complications and attributed them to the presence of muscle of fibers in the excised doughnut specimens.

Materials and Methods A prospective observational analysis of histopathological specimens obtained from patients who underwent stapled hemorrhoidopexy using procedure for prolapse and hemorrhoids-03 circular staplers in the department of surgery of a tertiary care hospital in southern India was performed, and the correlation between the presence or absence of muscle fibers in the specimens and postoperative complications was evaluated. The patients were followed up for 12 months after the procedure.

Results In this study, 155 patients, including 54, 91, and 10 patients with Grade 2, Grade 3, and Grade 4 hemorrhoids, respectively, were included. Group A consisted of 19 patients with muscle fibers on the specimens, whereas Group B consisted of 139 patients without muscle fibers on the specimens. Early complications within 7 days after the procedure were as follows: 21 and 0.7% of the patients in Groups A and B, respectively, presented with postoperative pain with a visual analog scale score of more than 4; 47 and 6% of the patients in Groups A and B, respectively, presented with urinary retention; 26 and 2% of the patients in Groups A and B, respectively, presented with bleeding; and 21 and 2.9% of the patients in Groups A and B, respectively, presented with fecal urgency. A significant association was found between the presence of muscle fibers and early complications (p < 0.001). Late complications, such as proctalgia and bleeding, accounting for 36.8 and 6.6% in Groups A and B, respectively, were significantly associated with the presence of muscle fibers in histopathology (p < 0.001). Meanwhile, other late complications, such as incontinence, stenosis, and recurrence, exhibited no association (p > 0.05).

Conclusion The technique in taking purse-string sutures and the depth of the suture bite above the dentate line carry the utmost importance in preventing postoperative complications. Therefore, surgeons should refine their technique of appropriate depth to avoid incorporation of muscle fibers while executing the procedure.

Stapled haemorrhoidopexy: is it time to move on?

Stapled haemorrhoidectomy was proposed as an 'ideal' solution for symptomatic haemorrhoids, with minimal postoperative pain, no perianal wound requiring postoperative wound care and a relatively short operative time. Some randomised controlled trials and reviews confirmed these findings, claiming that stapled haemorrhoidopexy is the most effective and safe procedure for haemorrhoids. However, there are increasing number of publications highlighting that the technique is associated with serious and life threatening complications. Maybe it is now the time to accept that stapled haemorrhoidopexy has done its role in directing our attention to the fact that modern surgical treatment of haemorrhoids should avoid excision of anorectal skin but should instead aim at treatment intervention above the dentate line.

Hemorrhoidal artery ligation (HAL) and rectoanal repair (RAR): retrospective analysis of 408 patients in a single center

BACKGROUND

Rectoanal repair (RAR), which combines doppler-guided hemorrhoidal artery ligation (HAL) and mucopexy via lifting of the hemorrhoidal prolapse, offers a minimally invasive alternative to conventional hemorrhoidectomy.

METHODS

Patients with grade II hemorrhoids were treated with HAL, and patients with grade III and IV hemorrhoids were treated with the RAR procedure by two surgeons. Postoperative follow-up was performed clinically and by proctoscopy after 8 weeks routinely, and long-term follow-up was performed using a standardized postal questionnaire.

RESULTS

The overall complication rate was 29% (n = 118). After short-term follow-up, 26% (n = 106) of patients reported recurrent or persistent prolapsing piles, while 21% (n = 86) of patients had recurrent bleeding. After long-term follow-up, 24% (n = 98) of patients reported prolapsing piles, 3% (n = 12) bleeding, 3% (n = 12) pruritus, and 2% (n = 8) anal pain, while 20% (n = 82) complained of persistent mixed symptoms.

CONCLUSIONS

HAL and RAR provide prolonged relief for patients with hemorrhoidal disease whose main symptoms are bleeding, pruritus and pain but not for patients with prolapse as an initial indication.

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.

Procedure for prolapse and hemorrhoids for grade III and IV internal hemorrhoids: A systematic review

Procedure for prolapse and hemorrhoids (PPH) is a new surgical technique that was developed based on the modern concept of internal hemorrhoids. It has gained wide acceptance as the treatment of choice for grade III and IV internal hemorrhoids, because of less postoperative pain and faster return to normal activities. Here we perform a systematic review on the recent advances in PPH for grade III and IV internal hemorrhoids.

Underlying functional bowel disorder may explain patient dissatisfaction after haemorrhoidal surgery

AIM

The aim of this study was to assess patient dissatisfaction and functional symptoms following haemorrhoid surgery, aspects of which are seldom covered in other published series.

METHOD

A self-administered questionnaire was mailed to 359 consecutive patients (prospective database; 198 men, 161 women; median follow up, 59 [1-120] months) who underwent either Milligan-Morgan haemorrhoidectomy (n=205) or stapled haemorrhoidopexy (n=154).

RESULTS

The response rate was 72%; 2.4% of patients had no opinion, 13.6% were dissatisfied, 33.0% were satisfied, and 51.0% were very satisfied with the treatment. Dissatisfied patients were more likely to be women and more likely to have a long history of constipation and irritable bowel syndrome. The duration of surgery and the rates of pre- and postoperative complications did not differ between groups. Residual bleeding (49% vs 32%), prolapse (67% vs 31%) and pain (91% vs 55%) occurred more frequently in the dissatisfied group compared with the satisfied group (P<0.001). Incontinence (4 [0-16] vs 1 [0-15]; P=0.0003) and constipation (19 [1-34] vs 8 [0-31]; P<0.0001) scores were significantly higher in the dissatisfied group compared with satisfied patients. Anal pain was the predominant symptom associated with dissatisfaction in a logistic regression model.

CONCLUSION

Persistent pain remains the major long-term factor associated with dissatisfaction after surgery for haemorrhoids.

The prevalence of hemorrhoids in adults

INTRODUCTION

Exact data on the prevalence of hemorrhoids are rare. Therefore, we designed a study to investigate the prevalence of hemorrhoids and associated risk factors in an adult general population.

METHODS

Between 2008 and 2009, consecutive patients were included in a prospective study. They attended the Austrian national wide health care program for colorectal cancer screening at four medical institutions. A flexible colonoscopy and detailed examination were conducted in all patients. Hemorrhoids were defined according to a standardized grading system. Independent variables included baseline characteristics, sociodemographic data, and health status. Potential risk factors were calculated by univariate and multivariate analysis.

RESULTS

Of 976 participants, 380 patients (38.93%) suffered from hemorrhoids. In 277 patients (72.89%), hemorrhoids were classified as grade I, in 70 patients (18.42%) as grade II, in 31 patients (8.16%) as grade III, and in 2 patients (0.53%) as grade IV. One hundred seventy patients (44.74%) complained about symptoms associated with hemorrhoids, whereas 210 patients (55.26%) reported no symptoms. In the univariate and multivariate analysis, body mass index (BMI) had a significant effect on the occurrence of hemorrhoids with p = 0.0391 and p = 0.0282, respectively. Even when correcting for other potential risk factors, an increase in the BMI of one increased the risk of hemorrhoids by 3.5%.

CONCLUSION

Hemorrhoids occur frequently in the adult general population. Notably, a considerable number of people with hemorrhoids do not complain about symptoms. In addition, a high BMI can be regarded as an independent risk factor for hemorrhoids.

Haemorrhoids, constipation and faecal incontinence: is there any relationship?

AIM

Little is known about the association of haemorrhoids and anorectal function. Moreover, available data on the impact of constipation on the presence of haemorrhoids are conflicting. The present study aimed to assess any potential relationship between haemorrhoids and anorectal dysfunction.

METHOD

All participants who attended the Austrian nationwide healthcare programme for colorectal cancer screening at four medical institutions were enrolled prospectively between 2008 and 2009. A colonoscopy and detailed anorectal examination were performed on all patients. Haemorrhoids were classified according to an international grading system. Faecal incontinence was defined as the involuntary loss of solid stool, liquid stool or gas, at least once a month. Constipation was recorded by a constipation scoring system.

RESULTS

Of 976 participants, 380 (38.9%) were found to have haemorrhoids. There was an association between healthy individuals, patients with symptomatic and patients with asymptomatic haemorrhoids and incontinence of liquid stool. No association was found regarding incontinence for solid stool and gas. The median constipation score was significantly higher in those patients with haemorrhoids (grade I-IV) compared with patients without haemorrhoids (2.5 points (range, 0-19) and 3 points (range, 0-19); P = 0.0113). 'Painful evacuation effort' and 'assistance for defaecation (stimulant laxatives, digital assistance or enema)' showed a significant correlation with haemorrhoids (P = 0.0394 and P = 0.0143).

CONCLUSION

Although the median constipation score was low in both groups, there was a significant association between constipation and haemorrhoids in adult patients.

Haemorrhoids and quality of life

AIM

There are few studies into the quality of life of patients with haemorrhoids. The aim of this study was to assess the quality of life of patients with haemorrhoids in an adult general population.

METHOD

Participants, who attended the Austrian nationwide healthcare programme for colorectal cancer screening at four medical institutions, were enrolled prospectively between 2008 and 2009. A colonoscopy was performed in all patients. Haemorrhoids were classified according to an international grading system and defined as symptomatic in cases with bleeding, itching, soiling or pain. Quality of life was measured by the Short Form-12 Health Survey.

RESULTS

Of 976 participants, 380 patients (39%) had haemorrhoids. The median physical health score was 52.6 (range 20.6-61.3) in the symptomatic and 53.2 (range 16.2-61.3) in the asymptomatic group (P = 0.7993). The median mental health score showed also no significant difference between both groups [symptomatic group, 52.8 (range 12.4-62.6); asymptomatic group, 54.8 (range 18.7-67.2); P = 0.0738].

CONCLUSION

Haemorrhoids, irrespective of their degree, do not influence quality of life measured by the Short Form-12 Health Survey.