Circumferential mucosectomy with stapled proctopexy is a safe, effective outpatient alternative for the treatment of symptomatic prolapsing hemorrhoids in the elderly

Ambulatory haemorrhoidal surgery: systematic literature review and qualitative analysis

PURPOSE

The aims of this study are to review the advantages and drawbacks of the ambulatory management of patients scheduled for haemorrhoidal surgery and to highlight the reasons for unplanned hospital admission and suggest preventive strategies.

METHODS

We conducted a systematic review of the literature from January 1999 to January 2013 using MEDLINE and EMBASE databases. Manuscripts were specifically analysed for failure and side effects of haemorrhoidal surgery in ambulatory settings.

RESULTS

Fifty relevant studies (6082 patients) were retrieved from the literature review. The rate of ambulatory management failure ranged between 0 and 61%. The main reasons for failure were urinary retention, postoperative haemorrhage and unsatisfactory pain control. Spinal anaesthesia was associated with the highest rates of urinary retention. Doppler-guided haemorrhoidal artery ligation has less frequent side effects susceptible to impair ambulatory management than haemorrhoidectomy and stapled haemorrhoidopexy. However, the fact that haemorrhoidopexy is less painful than haemorrhoidectomy may allow ambulatory management.

CONCLUSION

Day-case haemorrhoidal surgery can be performed whatever the surgical procedure. Postoperative pain deserves special prevention measures after haemorrhoidectomy, especially by using perineal block or infiltrations. Urinary retention is a common issue that can be responsible for failure; it requires a preventive strategy including short duration spinal anaesthesia. Doppler-guided haemorrhoidal artery ligation is easy to perform in outpatients but deserves more complete evaluation in this setting.

Massive prolapsed haemorrhoids managed by ablation and correction in a poor resourced area

More recently some patients with rectal mucosal prolapse and obstructive defaecation have been treated with the procedure for prolapse and haemorrhoids. We report a case of symptomatic chronic circumferentially prolapsed haemorrhoids that had several failed attempts at surgical repair. This was finally managed by ablation and correction of the associated rectal mucosal prolapse by a modified ‘Delorme's procedure akin to a stapled anopexy.

Haemorrhoidectomy by vessel sealing system under local anaesthesia in an outpatient setting: preliminary experience

AIM

This prospective study was designed to assess the feasibility of local anaesthesia for LigaSure haemorrhoidectomy in an outpatient setting.

METHOD

From April 2006 to March 2007, 207 consecutive patients (median age 42, 126 males) with grade III (147) and grade IV (60) haemorrhoids, underwent Milligan-Morgan haemorrhoidectomy with LigaSure under local anaesthesia (lidocaine 1%, mean dose 27 +/- 1.7 ml) in an outpatient setting. Postoperative pain was assessed by a visual analogue scale (VAS).

RESULTS

Two, three and four files were removed in 120, 51 and 36 patients. Mean operative time was 12 +/- 5.2 min and mean blood loss was 3.4 +/- 3.9 ml. The mean postoperative pain scores were 6.2 +/- 2.1 for the maximal pain intensity and 6.1 +/- 2.5 for the pain on defecation. All patients left hospital after surgery within 2 h and 33 (15.9%) required analgesics. They returned to normal daily activity after 12.2 +/- 7.9 days including work (12.1 +/- 7.8 days). The wounds had healed by 32.2 +/- 9.1 days. At a follow-up of at least 6 months, only six cases of major bleeding had occurred and 24 patients had skin tags. The median satisfaction score was +2 (-2 to +3).

CONCLUSION

LigaSure haemorrhoidectomy under local anaesthesia in the outpatient setting is safe and effective.

Pelvic sepsis after stapled hemorrhoidopexy

Stapled hemorrhoidopexy is a surgical procedure used worldwide for the treatment of grade III and IV hemorrhoids in all age groups. However, life-threatening complications occur occasionally. The following case report describes the development of pelvic sepsis after stapled hemorrhoidopexy. A literature review of techniques used to manage major septic complications after stapled hemorrhoidopexy was performed. There is no standardized treatment currently available. Stapled hemorrhoidopexy is a safe, effective and time-efficient procedure in the hands of experienced colorectal surgeons.

Circular stapled hemorrhoidopexy: experience of a single center with 445 cases

This study was designed to review the results of circular stapled hemorrhoidopexy (CSH) in the management of second-, third-, and fourth-degree hemorrhoidal disease. The medical records of 483 patients who had undergone circular stapled hemorrhoidopexy for symptomatic hemorrhoidal disease from June 2001 to September 2006 were evaluated. Data regarding complications, residual symptoms, and recurrence were collected. The study included 445 patients (283 men, 162 women) between 22 and 74 years old (median age 39 years). This constituted 92% of all patients. Concomitant lateral internal sphincterotomy, skin tags' excision, and thrombus removal were done in 106 (24.0%), 83 (18.5%), and 20 (4.5%) patients, respectively. The median operating time was 24 minutes (10-45 minutes). The median hospital stay was 40 hours (11-72 hours). Complications during the first 24 hours were fecal urgency (25%), urinary retention (8%), and rectal bleeding (1%). Pruritus ani (21%), thrombosed external hemorrhoids (4%), staple line stenosis (2%), rectal bleeding (2%), anal fissure (1%), and persistent skin tags (3%) were the symptoms seen during the long-term follow-up. The median follow-up was 23 months (6-70 months). The recurrence rate was 1%. Circular stapled hemorrhoidopexy can be safely performed with low recurrence and complication rates while offering a relatively painless postoperative period for the patient.

Stapled anopexy: postoperative course and functional outcome in 400 patients

PURPOSE

We performed a retrospective analysis of postoperative course and functional outcome after at least six months' follow-up in a series of 400 consecutive patients who underwent stapled anopexy.

METHODS

All patients were evaluated at one week and one month after surgery and then according to symptoms. A clinical or telephone follow-up was obtained for all patients. The last 50 patients were prospectively evaluated with an obstructive defecation syndrome score and Wexner continence and constipation score before operation and six months after anopexy.

RESULTS

There were no intraoperative complications. Postoperative bleeding that requires reoperation was observed in 11 patients, most cases (9/11) occurring in the early experience (first 50 patients). After a median follow-up of 6.1 years, four patients required reoperation. After anopexy, we observed an improvement in patients who present disturbance in defecation. The difference between the median obstructive defecation syndrome score before and after operation was statistically significant. Wexner score showed improvement without significant difference.

CONCLUSIONS

Treatment of hemorrhoids with circular stapler seems to be effective with low morbidity and high satisfaction rate because of reduced postoperative pain and rapid recovery. This technique also allows improvement of obstructive defecation symptoms, which are seldom studied in patients with hemorrhoids.

Harmonic scalpel® hemorrhoidectomy: A painless procedure?

Since the surgical treatment of hemorrhoidal disease has been characterized by intense postoperative pain, recent studies have tried to modify the standard Milligan-Morgans technique. The up-to-date literature, in the experience of authors, has confirmed that the new method of Harmonic Scalpel? hemorrhoidectomy reduces postoperative pain. The aim of our study was to statistically evaluate, based on our experience, the efficacy of this surgical approach in terms of reducing postoperative pain and establishing a stable hemostasis. Seventy-seven (77) patients suffering from hemorrhoid disease, stage III and IV, underwent surgery in our clinic during the last five years. The postoperative pain was determined using the visual analog scale on the 1st, 2nd and 7th postoperative days. Patients were divided into two groups in regard to the surgical procedure applied. The data were statistically processed using the Statistica 7.0 software. We concluded that Harmonic Scalpel? hemorrhoidectomy, due to less thermal damage, statistically significantly reduced postoperative pain with better hemostasis, compared with Milligan-Morgan's method of treating hemorrhoidal disease. .

Stapled hemorrhoidectomy under local anesthesia: tips and tricks

Stapled hemorrhoidectomy--a new, evolving technique--is considered to be safe and painless. General and spinal anesthesia are the "gold standard" anesthetic techniques for the procedure. The stapled hemorrhoidectomy under local anesthesia is described. Emphasis is given in few tips and tricks for safe and successful application of the local anesthesia.