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

Surgical treatment of recurrent prolapse after stapled haemorrhoidopexy

BACKGROUND

Recurrent prolapse after stapled haemorrhoidopexy is a late complication of the procedure which can present with accompanying symptoms and may require surgery. We describe a technique for treating symptomatic patients, aimed at obtaining remission of symptoms and avoiding recurrences.

METHODS

After excisional haemorrhoidectomy, a transverse incision is performed on the proximal part of the mucocutaneous bridge, above the plane of the internal sphincter. A flap of anal mucosa is gently raised. Haemorrhoidal tissue is not removed. LigaSure™ may be useful in focussing coagulation and reducing heat diffusion. Denudation of the internal sphincter allows the removal of potential retained staples. Then, stitches are placed between the proximal part of the flap and the proximal divided edge of the rectal mucosa. Excessive devascularisation of the flap must be avoided.

RESULTS

From January 2007 to January 2011, we treated 11 patients. The procedures lasted a mean of 38.2 ± 11.1 min. One patient (9 %) suffered from bleeding during the night before being discharged, but this did not require surgery, and another (9 %) had urinary retention. No other perioperative complications were observed. The mean visual analogue scale score 1 day and 1 week after surgery was 4.7 ± 1.3 and 2.3 ± 0.5, respectively. At mean follow-up of 4 ± 1.8 years, neither symptomatic nor asymptomatic recurrences have been observed. Two out of three patients presenting with urgency reported regression of symptoms (66.7 %). In all patients suffering from pain after stapled haemorrhoidopexy, the procedure achieved pain relief (2/2, 100 %). No stenoses occurred.

CONCLUSIONS

This technique is a promising alternative after failed stapled haemorrhoidopexy. Morbidity is low. The procedure may effectively treat associated symptoms.

Outcome of repeated stapler haemorrhoidopexy for recurrent prolapsing haemorrhoids

AIM

Stapled haemorrhoidopexy (SH) is associated with minor postoperative pain and high overall satisfaction rates. Some patients will have persistent or recurrent symptoms requiring re-intervention.

METHOD

All patients who underwent SH for grade III internal haemorrhoids and required a second SH (2005-2008) were studied. Grade IV patients were excluded. Data on surgical technique, postoperative pain, complications, time to first bowel movement, functional recovery and suspected reason for first SH failure were retrieved from medical records. Similar data were collected for the second procedure at four postoperative follow-up visits.

RESULTS

Twelve patients were enrolled. The mean time to recurrent symptoms was 15 months. The indications for repeated surgery were bleeding, prolapse, and pruritus w/wo discharge. Recurrence was attributed to a too high staple line in the first procedure (n = 4) and an incomplete resected ring (n = 1). The median operative time of the second procedure was 24 min (17-29) and the median follow up was 20 ± 4.3 months (15-30). Repeat SH was associated with higher pain scores, more analgesic requirements, and longer recovery period compared to the first procedure. There were no early or late postoperative complications. Histological examination of the 12 tissue doughnuts resected during the second SH showed no smooth muscle fibres in any of the patients. After 12 months of follow up, 10 patients with repeated SH remained asymptomatic, while 2 had recurrent bleeding.

CONCLUSION

Repeat SH can be performed safely and reliably without risk of complications, but the second SH is associated with more pain and longer recovery time.

Residual skin tags following procedure for prolapse and hemorrhoids: differentiation from recurrence

PURPOSE

The aim of this study was to compare the incidence of recurrence and residual skin tag after the procedure for prolapse and hemorrhoids (PPH) versus conventional hemorrhoidectomy (CH) in the Chinese- and English-language literature to explore the definition of recurrence after PPH.

METHODS

Related Chinese- and English-language literature was collected by several methods. Meta-analysis was used to compare the incidence of recurrence and residual skin tag of PPH versus CH.

RESULTS

In China, 13.94% of hemorrhoids had a skin tag after PPH. The mean recurrence rate after PPH was 3.23% (range 0.40-26.44%). Our meta-analysis of PPH versus CH of the Chinese studies showed that PPH had a significantly lower recurrence rate-13 studies, odds ratio (OR) 0.27, 95% confidence interval (CI) 0.17-0.42, p < 0.00001-and a higher incidence of skin tags with no significance-6 studies, OR 3.42, 95% CI 0.49-24.04, p = 0.22. Our meta-analysis of PPH versus CH among the English-language studies showed that PPH had a significantly higher recurrence rate-17 studies, 636 patients in the PPH group vs. 625 patients in the CH group, OR 2.96, 95% CI 1.57-5.56, p = 0.0008-and a significantly higher incidence of residual skin tags-8 studies, 297 patients in the PPH group vs. 289 patients in the CH group, OR 1.88, 95% CI 1.15-3.05, p = 0.01. However, the recurrence of prolapse was stated to be ascertained by anorectal examination in only six studies; meta-analysis of the six studies showed that PPH was not associated with a higher recurrence-six studies, 230 patients in the PPH group vs. 220 patients in the CH group; OR 1.87, 95% CI 0.70-5.00, p = 0.22.

CONCLUSIONS

PPH is not associated with a higher recurrence rate but is associated with a higher incidence of skin tags compared with CH. The reported high recurrence rates are probably caused by improper inclusion of residual skin tags into the recurrence data. Surgeons should perform anorectal examinations to differentiate a residual skin tag from a recurrence.