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Abbas MA. Minimally invasive proctologic procedures [MIPP]: the quest for less pain, safer surgery, and faster recovery. SEMINARS IN COLON AND RECTAL SURGERY 2019. [DOI: 10.1016/j.scrs.2019.100700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Prospective, Multicenter Randomized Controlled Trial Comparing Two Hemorrhoidopexy Staplers: The HEMOSTASIS Study. Int Surg 2018. [DOI: 10.9738/intsurg-d-15-00171.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The objective of this study was to compare two hemorrhoidopexy staplers (EEA versus PPH03). Stapled hemorrhoidopexy is a treatment option for patients with symptomatic internal hemorrhoids who have failed more conservative measures. However, staple line bleeding remains common. Recent improvements in stapler design have attempted to reduce intraoperative bleeding and the need for intervention. HEMOSTASIS is a prospective, multicenter, 1:1 randomized controlled trial. Twelve hospital centers in the United States enrolled participants between 18 and 85 years of age with symptomatic grades 2 to 3 internal hemorrhoids. The primary end point was intraoperative bleeding, defined as bleeding requiring intervention (e.g., placement of sutures, cauterization, or ligation to achieve hemostasis). Secondary end points included staple line location, postoperative pain, quality of life, operative time, length of hospital stay, adverse events, and complication rates. On the primary end point, the rates of intraoperative bleeding requiring intervention were 41.0% (32 of 78) with EEA and 70.4% (50 of 71) with PPH (P < 0.001). Treatment for active bleeding was required in 30.8% versus 57.7% (P < 0.001) in the EEA and PPH arms, respectively. There were no significant differences between groups in postoperative pain. Adverse events and perioperative complication rates were generally mild/moderate and were similar between groups: 74.1% (60 of 81) of patients in the EEA group reported at least one adverse event versus 80.9% (55 of 68) in the PPH group (P = 0.32). Intraoperative bleeding occurred less often after stapled hemorrhoidopexy with the EEA stapler compared with the PPH03 stapler. Intervention to achieve hemostasis was required less often with the EEA stapler.
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Rodoman GV, Kornev LV, Shalaeva TI, Malushenko RN. [Efficiency of combined methods of hemorroid treatment using hal-rar and laser destruction]. Khirurgiia (Mosk) 2017:47-51. [PMID: 28514383 DOI: 10.17116/hirurgia2017547-51] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
AIM To develop the combined method of treatment of hemorrhoids with arterial ligation under Doppler control and laser destruction of internal and external hemorrhoids. MATERIAL AND METHODS The study included 100 patients with chronic hemorrhoids stage II and III. Combined method of HAL-laser was used in study group, HAL RAR-technique in control group 1 and closed hemorrhoidectomy with linear stapler in control group 2. Сomparative evaluation of results in both groups was performed. RESULTS Combined method overcomes the drawbacks of traditional surgical treatment and limitations in external components elimination which are inherent for HAL-RAR. Moreover, it has a higher efficiency in treating of hemorrhoids stage II-III compared with HAL-RAR and is equally safe and well tolerable for patients. This method does not increase the risk of recurrence, reduces incidence of complications and time of disability.
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Affiliation(s)
- G V Rodoman
- Pirogov Russian National Research Medical University, Ministry of Health of the Russian Federation, Department of general surgery and x-ray diagnostics, medical faculty, Moscow
| | - L V Kornev
- Pirogov Russian National Research Medical University, Ministry of Health of the Russian Federation, Department of general surgery and x-ray diagnostics, medical faculty, Moscow
| | - T I Shalaeva
- Pirogov Russian National Research Medical University, Ministry of Health of the Russian Federation, Department of general surgery and x-ray diagnostics, medical faculty, Moscow
| | - R N Malushenko
- Russian Peoples' Friendship University, Department of ultrasound diagnostics and surgery
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Sabanci U, Ogun I, Candemir G. Stapled Haemorrhoidopexy versus Ferguson Haemorrhoidectomy: A Prospective Study with 2-Year Postoperative Follow-up. J Int Med Res 2016; 35:917-21. [DOI: 10.1177/147323000703500622] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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).
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Affiliation(s)
- U Sabanci
- Department of General Surgery, Yuzuncu Yil University, Van, Turkey
| | - I Ogun
- Department of General Surgery, Ankara Military Hospital, Ankara, Turkey
| | - G Candemir
- Department of General Surgery, Ankara Military Hospital, Ankara, Turkey
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High-grade hemorrhoids requiring surgical treatment are common after laparoscopic ventral mesh rectopexy. Tech Coloproctol 2016; 20:235-42. [PMID: 26883036 PMCID: PMC4799262 DOI: 10.1007/s10151-016-1432-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 12/28/2015] [Indexed: 12/17/2022]
Abstract
Purpose To describe patients developing grade III and IV hemorrhoids requiring surgery after laparoscopic ventral mesh rectopexy (LVMR) and to explore the relationship between developing such hemorrhoids and recurrence of rectal prolapse after LVMR. Methods All consecutive patients receiving LVMR at the Meander Medical Centre, Amersfoort, the Netherlands, between 2004 and 2013 were analyzed. Kaplan–Meier estimates were calculated for recurrences. Results A total of 420 patients underwent LVMR. Sixty-five of these patients (actuarial 5-year incidence 24.3, 95 % confidence interval (CI) 18.6–30.0) developed symptomatic grade III/IV hemorrhoids requiring stapled or excisional hemorrhoidectomy. Re-do surgery for recurrent grade III/IV hemorrhoids was required for 15 of the 65 patients (actuarial 5-year recurrence rate 40.6, 95 % CI 23.2–58.0) after the primary hemorrhoidectomy. Three of the 65 patients developed an external rectal prolapse (ERP) recurrence and eight an internal rectal prolapse (IRP) recurrence. This generated a 5-year recurrence rate of 25.3 % (95 % CI 0–53.9) for ERP recurrence and 24.4 % (95 % CI 9.1–39.7) for IRP recurrence. The rest of the LVMR cohort not receiving additional surgery for hemorrhoids (n = 355) showed significantly lower actuarial 5-year ERP (0.8 %, p = 0.011) and IRP (11 %, p = 0.020) recurrence rates. Conclusion High-grade hemorrhoids requiring surgery may be common after LVMR. The development of high-grade hemorrhoids after LVMR might be considered a predictor of rectal prolapse recurrence.
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Grigoropoulos P, Kalles V, Papapanagiotou I, Mekras A, Argyrou A, Papageorgiou K, Derian A. Early and late complications of stapled haemorrhoidopexy: a 6-year experience from a single surgical clinic. Tech Coloproctol 2012; 15 Suppl 1:S79-81. [PMID: 21912950 DOI: 10.1007/s10151-011-0739-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE Introduction of stapled hemorrhoidopexy (SH) brought a radical change in the treatment of haemorrhoidal disease. The aim of this study is to evaluate the results and the complications (early and late) from the use of this technique. METHODS During the last 6 years (2005-2011), 123 patients underwent a SH in our ward. Our sample consists of 79 male and 44 female patients with an average age of 48.2 years (range 22-83 years). Of them, 83 had third-degree haemorrhoidal disease, 34 had fourth-degree and 6 had second-degree bleeding haemorrhoids. The follow-up period was 6-72 months. RESULTS Pain was minimal or even not existent. Additional sutures or use of adrenaline 1:200.000 for haemostasis were required in 6 patients (4.8%). The bleeding has been diminished with the use of this new haemorrhoidectomy stapler PPH03. Urinary retention, which was observed in 3 patients (2.4%), was temporary and the use of catheter was not needed. As a late complication, 'faecal urgency' occurred in 8 patients (6.5%), and disappeared after some months. No recurrent haemorrhoidal disease occurred. No cases of chronic pain were reported. Average hospital stay was 1 day, except for 2 patients who remained for 2 days for bleeding observation. CONCLUSIONS The correct application of SH reduces the possible complications. The advantages of the stapled procedure are reduced postoperative pain, the minimal hospital stay and early return to work.
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Affiliation(s)
- P Grigoropoulos
- 1st Surgical Clinic, First IKA Hospital, Lamera 31, Nea Makri, 19005 Attiki, Greece.
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Do dietary spices impair the patient-reported outcomes for stapled hemorrhoidopexy? A randomized controlled study. Surg Endosc 2010; 25:1535-40. [DOI: 10.1007/s00464-010-1431-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2010] [Accepted: 09/27/2010] [Indexed: 12/17/2022]
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Jongen J, Eberstein A, Bock JU, Peleikis HG, Kahlke V. Complications, recurrences, early and late reoperations after stapled haemorrhoidopexy: lessons learned from 1,233 cases. Langenbecks Arch Surg 2009; 395:1049-54. [PMID: 19639336 DOI: 10.1007/s00423-009-0543-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2009] [Accepted: 07/10/2009] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Johannes Jongen
- Proctological Office Kiel, Beselerallee 67, 24105, Kiel, Germany.
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Uras C, Baca B, Boler DE. Circular stapled hemorrhoidopexy: experience of a single center with 445 cases. World J Surg 2008; 32:1783-8. [PMID: 18553195 DOI: 10.1007/s00268-008-9627-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2007] [Accepted: 03/30/2008] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Cihan Uras
- Department of Surgery, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
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Lai HJ, Jao SW, Su CC, Lee MC, Kang JC. Stapled hemorrhoidectomy versus conventional excision hemorrhoidectomy for acute hemorrhoidal crisis. J Gastrointest Surg 2007; 11:1654-61. [PMID: 17909924 DOI: 10.1007/s11605-007-0259-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2007] [Accepted: 07/19/2007] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Huang-Jen Lai
- Division of Colorectal Surgery, Department of Surgery, Buddhist Tzu Chi General Hospital, Tzu Chi University, Hualien, Taiwan
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Huang WS, Lin PY, Chin CC, Yeh CH, Hsieh CC, Chang TS, Wang JY. Stapled hemorrhoidopexy for prolapsed hemorrhoids in patients with liver cirrhosis; a preliminary outcome for 8-case experience. Int J Colorectal Dis 2007; 22:1083-9. [PMID: 17334772 DOI: 10.1007/s00384-007-0271-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/04/2007] [Indexed: 02/04/2023]
Abstract
PURPOSE To investigate the efficacy and safety of stapled hemorrhoidopexy in treating prolapsed hemorrhoids in patients with liver cirrhosis. PATIENTS AND METHODS Eight consecutive cases of patients with prolapsed hemorrhoids comorbid with liver cirrhosis, who had intractable response to other interventions, were enrolled in this retrospective study between January 2002 and June 2006 at our institute. Six patients (75%) had Child-Pugh class A liver cirrhosis, whereas only two patients (25%) had class B disease. Rectal varices were identified in three patients (37.5%), and esophageal varices were identified in six patients (75%). Concurrent rectal and esophageal varices existed in three patients (37.5%). The patients underwent stapled hemorrhoidopexy with Proximate PPH-03 in a lithotomy position under spinal/intravenous general anesthesia. RESULTS There was no procedure-related mortality or major complications except hemorrhage. Two patients (25%) were complicated with postoperative staple-line bleeding, which was managed with conservative treatment without reoperation. There were no leading symptoms of relapsing during a follow-up period of at least 6 months. CONCLUSIONS This study may prove that stapled hemorrhoidopexy is a feasible and safe approach for prolapsed hemorrhoids concurrent with liver cirrhosis.
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Affiliation(s)
- Wen-Shih Huang
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, 6, Sec. West, Chia-Pu Road, Putz, Chiayi 613, Taiwan
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Huang WS, Chin CC, Yeh CH, Lin PY, Wang JY. Randomized comparison between stapled hemorrhoidopexy and Ferguson hemorrhoidectomy for grade III hemorrhoids in Taiwan: a prospective study. Int J Colorectal Dis 2007; 22:955-61. [PMID: 17171354 DOI: 10.1007/s00384-006-0244-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/20/2006] [Indexed: 02/04/2023]
Abstract
PURPOSE Short-term and mid-term outcomes of stapled hemorrhoidopexy (SH) were compared with those for Ferguson hemorrhoidectomy (FH) for treating hemorrhoids. MATERIALS AND METHODS Patients with prolapsed hemorrhoids were randomized into two groups treated with SH (N = 300) and FH (N = 296) at Chang Gung Memorial Hospital at Chiayi in Taiwan between January 2002 and December 2004. The outcomes of the procedures were evaluated postoperatively (short-term, i.e., intra-/postoperative conditions, hospital stay, pain intensity scoring, time off work, and procedure-related morbidity) and over a follow-up period of minimum 18 months (mid-term, i.e., relapse of prolapse and/or bleeding, anal stricture, anal sepsis, and the acceptability of the procedures to the patients). RESULTS SH was superior to FH in operative time, intraoperative blood loss, postoperative pain intensity, and return to work. Based on telephone interviews over the follow-up period, most patients who received SH appreciated the procedure better than those with FH. CONCLUSIONS This study confirms that SH generates less postoperative suffering, less time off work, and more complete resolution of primary symptoms associated with hemorrhoids in the mid-term follow-up than FH.
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Affiliation(s)
- Wen-Shih Huang
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, 6, Sec West, Chia-Pu Road, Putz, Chiayi, Taiwan.
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Tjandra JJ, Chan MKY. Systematic review on the procedure for prolapse and hemorrhoids (stapled hemorrhoidopexy). Dis Colon Rectum 2007; 50:878-92. [PMID: 17380367 DOI: 10.1007/s10350-006-0852-3] [Citation(s) in RCA: 175] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The procedure for prolapse and hemorrhoids (stapled hemorrhoidopexy) has been introduced as an alternative to conventional hemorrhoidectomy. This is a systematic review on stapled hemorrhoidopexy of all randomized, controlled trials that have been published until August 2006. METHODS All published, randomized, controlled trials comparing stapled hemorrhoidopexy to conventional hemorrhoidectomy were identified from Ovid MEDLINE, EMBASE, CINAHL, and all Evidence-Based Medicine Reviews (Cochrane Central Register of Controlled Trial, Cochrane Database of Systemic Review, and Database of Abstracts of Reviews of Effects) between January 1991 and August 2006. Meta-analysis was performed by using the Forest plot review if feasible. RESULTS A total of 25 randomized, controlled trials with 1,918 procedures were reviewed. The follow-up duration was from 1 to 62 months. Stapled hemorrhoidopexy was associated with less operating time (weighted mean difference, -11.35 minutes; P = 0.006), earlier return of bowel function (weighted mean difference -9.91 hours; P < 0.00001), and shorter hospital stay (weighted mean difference, -1.07 days; P = 0.0004). There was less pain after stapled hemorrhoidopexy, as evidenced by lower pain scores at rest and on defecation and 37.6 percent reduction in analgesic requirement. The stapled hemorrhoidopexy allowed a faster functional recovery with shorter time off work (weighted mean difference, -8.45 days; P < 0.00001), earlier return to normal activities (weighted mean difference, -15.85 days; P = 0.03), and better wound healing (odds ratio, 0.1; P = 0.0006). The patients' satisfaction was significantly higher with stapled hemorrhoidopexy than conventional hemorrhoidectomy (odds ratio, 2.33; P = 0.003). Although there was increase in the recurrence of hemorrhoids at one year or more after stapled procedure (5.7 vs. 1 percent; odds ratio, 3.48; P = 0.02), the overall incidence of recurrent hemorrhoidal symptoms--early (fewer than 6 months; stapled vs. conventional: 24.8 vs. 31.7 percent; P = 0.08) or late (1 year or more) recurrence rate (stapled vs. conventional: 25.3 vs. 18.7 percent; P = 0.07)--was similar. The overall complication rate did not differ significantly from that of conventional procedure (stapled vs. conventional: 20.2 vs. 25.2 percent; P = 0.06). Compared with conventional surgery, stapled hemorrhoidopexy has less postoperative bleeding (odds ratio, 0.52; P = 0.001), wound complication (odds ratio, 0.05; P = 0.005), constipation (odds ratio, 0.45; P = 0.02), and pruritus (odds ratio, 0.19; P = 0.02). The overall need of surgical (odds ratio, 1.27; P = 0.4) and nonsurgical (odds ratio, 1.07; P = 0.82) reintervention after the two procedures was similar. CONCLUSIONS The Procedure for Prolapse and Hemorrhoid (stapled hemorrhoidopexy) is safe with many short-term benefits. The long-term results are similar to conventional procedure.
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Affiliation(s)
- Joe J Tjandra
- Department of Colorectal Surgery, Royal Melbourne Hospital and Epworth Hospitals, University of Melbourne, Melbourne, Australia.
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Martinsons A, Narbuts Z, Brunenieks I, Pavars M, Lebedkovs S, Gardovskis J. A comparison of quality of life and postoperative results from combined PPH and conventional haemorrhoidectomy in different cases of haemorrhoidal disease. Colorectal Dis 2007; 9:423-9. [PMID: 17504339 DOI: 10.1111/j.1463-1318.2006.01169.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To compare the early postoperative results and late patient-related postoperative results by a Short-Form 36 quality of life survey after conventional haemorrhoidectomy and PPH procedure with additional surgical intervention in noncomplicated, complicated and delayed cases of the disease. METHOD The comparison was made between comparable patient groups after conventional haemorrhoidectomy (n = 168) and after PPH with additional surgical intervention (n = 142). The early and late postoperative results and quality of life analysis according to SF-36 questionnaire were compared. RESULTS The length of procedure was significantly shorter after the PPH procedure (37.4 vs 49.4 min). The amount of postoperative nonopiate analgesics was similar, but consumption of opiates was more in the conventional group. The rate of early postoperative complications was similar. In the PPH group significant improvement in all quality of life parameters was ascertained 6 months after operation, but 6 weeks after surgery several parameters in this group were lower. In the conventional group improvement was ascertained only for several parameters. The significant improvement of quality of life after PPH operations was ascertained especially at a mean period of 6 weeks. CONCLUSION The PPH procedure performed in complex cases of the disease and combined with other surgical intervention because of the anorectal comorbidity assures better early postoperative results and better postoperative quality of life in a 6-month follow up in comparison with conventional haemorrhoidectomy. The continuation of quality of life studies with a longer follow up is required concerning Longo operation.
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Affiliation(s)
- A Martinsons
- Department of Surgery, Riga Stradina University, Riga, Latvia.
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Zaragozá C, García Fadrique A, Castaño S, Villalba R, Bruna Esteban M, Redondo Cano C. [Results of Longo's stapled hemorrhoidectomy in ambulatory surgery for grade III-IV hemorrhoids]. Cir Esp 2007; 81:130-3. [PMID: 17349236 DOI: 10.1016/s0009-739x(07)71283-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION We prospectively evaluated the results of stapled hemorrhoidectomy for grade III-IV hemorrhoids in the ambulatory setting. METHOD Eighty-five consecutive patients with grade III-IV hemorrhoids, treated with the stapled technique with PPH01 in the Ambulatory Surgery Service of the General Hospital of Valencia were studied. Symptomatic, ASA I-II patients who agreed to undergo ambulatory surgery (vehicle, an accompanying adult, address with telephone, elevator, and basic hygiene conditions) were included. RESULTS Thirty-nine percent were women and 61% were men, with a mean age of 47.6 years. A total of 85.9% had grade IV hemorrhoids and 14.1% had grade III. The average surgical time was 29.81+/- 12 minutes with a mean length of hospital stay of 168.88 +/- 88 minutes. Surgical complications consisted of 16 hemorrhages of the staple line (18.8%) and five hemorrhages due to mucous tear (5.9%). During the first 8 days the most frequent complication was pain (45.9%); only 7.1% of the patients required analgesia with opiates, and one patient required admission for 24 hours for analgesic purposes. Bleeding occurred in 10 patients, five of whom reported slight bleeding on defecation that stopped spontaneously; the remaining five required admission for 24 hours after surgical revision. Nine patients (10.6%) were admitted to the hospital for 24 hours, three due to intraoperative hemorrhage, five due to postoperative hemorrhage and one due to pain. A second intervention was required in 8.2%. CONCLUSIONS Stapled hemorrhoidectomy can be applied in an ambulatory regime. Although technically simple with a short learning curve, this technique is not free of complications. Suitable patient selection and adequate perioperative information are indispensable for the ambulatory management of this disorder.
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Affiliation(s)
- Cristóbal Zaragozá
- Servicio de Cirugía Mayor Ambulatoria (UCMA), Consorcio Hospital General Universitario, Valencia, España
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Williams R, Kondylis L, Geisler D, Kondylis P. Stapled hemorrhoidopexy height as outcome indicator. Am J Surg 2007; 193:336-9; discussion 339-40. [PMID: 17320530 DOI: 10.1016/j.amjsurg.2006.09.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2006] [Revised: 09/20/2006] [Accepted: 09/20/2006] [Indexed: 11/26/2022]
Abstract
BACKGROUND Postoperative expectations after stapled hemorrhoidopexy are still being clarified. Our purpose was to evaluate how outcome is affected by staple line height (SLH) above the dentate line and specimen histology. METHODS A prospective database identified demographics, SLH, histology, narcotic use, return to work, and resolution or recurrence of preoperative symptoms data for analysis. RESULTS One hundred five patients were analyzed; median age was 49 years. Median RTW and narcotic use were 9 and 4 days, respectively. Patients with squamous epithelium-containing specimens had longer narcotic use (P = .038), whereas patients with SLH >20 mm had shorter narcotic use (P = .021). Preoperative pain and bleeding resolved more frequently with SLH >20 mm (P = .036) and less frequently with SLH >40 mm (P = .032). Patients with poor sphincter tone were more likely to have SLH >20 mm (P = .044). Postoperative symptoms recurred more frequently in patients with SLH >40 mm (P = .001). CONCLUSIONS Hemorrhoidopexy SLH and histology can impact postoperative outcomes. SLH should be >20 mm yet < or =40 mm above the dentate, avoiding squamous epithelium.
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Affiliation(s)
- R Williams
- Saint Vincent Health Center, 232 West 25th Street, Erie, PA 16544, USA.
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17
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Fueglistaler P, Guenin MO, Montali I, Kern B, Peterli R, von Flüe M, Ackermann C. Long-term results after stapled hemorrhoidopexy: high patient satisfaction despite frequent postoperative symptoms. Dis Colon Rectum 2007; 50:204-12. [PMID: 17180255 DOI: 10.1007/s10350-006-0768-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- P Fueglistaler
- Surgical Department, St Claraspital, Basel, Switzerland.
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Yao L, Zhong Y, Xu J, Xu M, Zhou P. Rectal stenosis after procedures for prolapse and hemorrhoids (PPH)--a report from China. World J Surg 2006; 30:1311-5. [PMID: 16773258 DOI: 10.1007/s00268-005-0484-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES After it was introduced in China in 2000, the surgical procedure for prolapse and hemorrhoids (PPH) has become a widely accepted for third- and fourth-degree hemorrhoids. Stenosis of the lower rectum is one of the delayed complications. In order to evaluate this specific problem following PPH, we reviewed our data with special reference to potential predictive factors or stenotic events. METHODS A retrospective analysis of 554 consecutive patients that underwent PPH from July 2000 to December 2004 was performed. Only patients with follow-up check were evaluated; therefore 65 patients (11.7%) Hwere lost to follow-up, and the analysis therefore includes 489 patients with a mean follow-up of 324 days (+/-18 days). For statistical analysis, the groups with and without stenosis were evaluated using the chi-square test; using the Kaplan-Meier statistic, the actuarial incidence for rectal stenosis was plotted. RESULTS Rectal stenosis was observed in 12 patients (2.5%) in whom the median time to stenosis was 125 (89 approximately 134) days. All patients complained of obstructive defecation and underwent strictureplasty with electrocautery or balloon dilation through colonoscopy. A statistical analysis revealed that two factors were significantly more prevalent among patients with stenosis: prior sclerosis therapy for hemorrhoids (P=0.02) and severe postoperative pain (P=0.003). Other factors, such as gender (P=0.32), prior surgery for hemorrhoids (P=0.11), histological evidence of squamous skin (P=0.77) or revision (P=0.53) showed no significance. CONCLUSIONS Rectal stenosis is an uncommon event after PPH. Early stenosis will occur within the first 4 months after surgery. In most cases, the stenosis can be cured through colonoscopy surgery. Predictive factors for stenosis are previous sclerosis therapy for hemorrhoids and severe postoperative pain.
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Affiliation(s)
- Liqin Yao
- Department of General Surgery, Zhongshan Hospital, Fudan University Medical Center, Shanghai, 200032, People's Republic of China
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19
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Singer M, Cintron J. New techniques in the treatment of common perianal diseases: stapled hemorrhoidopexy, botulinum toxin, and fibrin sealant. Surg Clin North Am 2006; 86:937-67. [PMID: 16905418 DOI: 10.1016/j.suc.2006.06.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
There have been several recent advances in the treatment of common perianal diseases. Stapled hemorrhoidopexy is a procedure of hemorrhoidal fixation, combining the benefits of rubber band ligation into an operative technique. The treatment of anal fissure has typically relied upon internal sphincterotomy; however, it carries a risk of incontinence. The injection of botulinum toxin represents a new form of sphincter relaxation, without division of any sphincter muscle; morbidity is minimal and results are promising. For the treatment of fistula in a fistulotomy remains the gold standard, however, it carries significant risk of incontinence. Use of fibrin sealant to treat fistulae has been met with variable success. It offers sealing of the tract, and then provides scaffolding for native tissue ingrowth.
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Affiliation(s)
- Marc Singer
- Department of Surgery (MC958), University of Illinois, Clinical Sciences Building, #518-E, 840 S. Wood Street, Chicago, IL 60612, USA
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20
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Greenberg R, Karin E, Avital S, Skornick Y, Werbin N. First 100 cases with Doppler-guided hemorrhoidal artery ligation. Dis Colon Rectum 2006; 49:485-9. [PMID: 16435166 DOI: 10.1007/s10350-005-0281-8] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was designed to examine the benefits of a Doppler-guided hemorrhoidal artery ligation technique in terms of surgical outcome, functional recovery, and postoperative pain. METHODS Using local, regional, or general anesthesia, 100 patients with symptomatic Grades II or III hemorrhoids underwent sonographic identification and suture ligation of six to eight terminal branches of the superior rectal artery above the dentate line. Visual Analog Scales were used for postoperative pain scoring. Surgical and functional outcomes were assessed at 6 weeks and 3, 6, and 12 months after surgery. RESULTS There were 42 (42 percent) males and 58 (58 percent) females (mean age, 42 years; median duration of symptoms, 6.3 years). The mean operative time was 19 minutes. Local anal block combined with intravenous sedation (n = 93) or general or spinal (n = 7) anesthesia was used. Only five were hospitalized overnight. There was no urinary retention, bleeding, or mortality in the immediate postoperative course. The mean pain score decreased from 2.1 at two hours postoperative to 1.3 on the first postoperative day. All patients had a complete functional recovery by the third postoperative day. Ninety-four patients remained asymptomatic after a mean follow-up of six months: four patients required additional surgical excision, and two required rubber band ligations for persistent bleeding. On follow-up, there was no report of incontinence to gas or feces, fecal impaction, or persistent pain. CONCLUSIONS Our experience indicates that Doppler-guided hemorrhoidal artery ligation is safe and effective and can be performed as an outpatient procedure with local or regional anesthesia and with minimal postoperative pain and early recovery.
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Affiliation(s)
- Ron Greenberg
- Department of Surgery A', Tel-Aviv Medical Center and the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Jongen J, Bock JU, Peleikis HG, Eberstein A, Pfister K. Complications and reoperations in stapled anopexy: learning by doing. Int J Colorectal Dis 2006; 21:166-71. [PMID: 15951988 DOI: 10.1007/s00384-005-0784-8] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/28/2005] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Johannes Jongen
- Department of Surgical Proctology and Proctological Office, Park-Klinik, Goethestrasse 11, 24116, Kiel, Germany.
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Pérez-Vicente F, Arroyo A, Serrano P, Candela F, Sánchez A, Calpena R. Prospective randomised clinical trial of single versus double purse-string stapled mucosectomy in the treatment of prolapsed haemorrhoids. Int J Colorectal Dis 2006; 21:38-43. [PMID: 15843940 DOI: 10.1007/s00384-004-0720-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/10/2004] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Despite the excellent results published on circular stapled mucosectomy (CSM), there is still some concern about the application of PPH-33 in the advanced haemorrhoidal disease, where a major prolapse may lead to insufficient resection and ensuing early recurrence. This study is aimed at comparing the outcomes after single purse-string CSM versus double purse-string CSM. PATIENTS AND METHODS A prospective randomised clinical trial of single versus double purse-string CSM for grade III-IV symptomatic haemorrhoids was used. One hundred consecutive patients were randomised to single (group 1, N=50) versus double purse-string CSM (group 2, N=50). RESULTS The mean age was 50.7 years, with a predominance of males (63 vs. 37). Haemorrhoids were classified as grade III in 59% and grade IV in 41% of the patients. Mean follow-up was 26 months. Demographic and clinical features showed no differences between the two groups. The size of the resected doughnut was greater in group 2 (4.95 vs. 3.55 cm; p<0.05), as was the distance of the suture from the dentate line (3.56 vs. 3.16 cm; p<0.05). Early postoperative pain was significantly less in group 2 (linear analogue scale from 0 to 10), 2.08 vs. 3.56 (p<0.001). Postoperative haemorrhage was absent or minimal in 79% of patients. Three patients from group 1 reported persistent pain that was resolved within the first few postoperative months. There were two recurrences in group 1. CONCLUSION Double purse-string CSM resects a greater doughnut, increases the distance of the staple suture from the dentate line and reduces early postoperative pain in comparison to single purse-string CSM. Larger series are necessary to assert whether recurrence is lower.
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Affiliation(s)
- Francisco Pérez-Vicente
- Coloproctology Unit, Department of Surgery, University Hospital of Elche, C/Huertos y Molinos s/n, 03202, Elche, Alicante, Spain.
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Delikoukos S, Zacharoulis D, Hatzitheofilou C. Stapled hemorrhoidectomy under local anesthesia: tips and tricks. Dis Colon Rectum 2005; 48:2153-5. [PMID: 16228829 DOI: 10.1007/s10350-005-0178-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
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Abstract
AIM: To evaluate cost-effectiveness of stapled hemorrhoidectomy comparing its results with conventional technique. SOURCE OF DATA: We retrospectively analyzed the MEDLINE data basis from 2000 to 2004 studying randomized clinical trials which compared pain intensity, recovery period, return to work and occurrence of anal incontinence, in addition to postoperative complications and costs evaluation between stapled and conventional hemorrhoidectomy during different periods of follow-up. CONCLUSIONS: Stapled hemorrhoidectomy provides lesser postoperative pain and earlier return to work than conventional hemorrhoidectomy. However, its efficacy could not be determined, since rigorous prospective and randomized clinical trials with long-term follow-up periods and large size samples are not available at this time.
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Affiliation(s)
- Antônio Lacerda-Filho
- Department of Surgery, Federal University of Minas Gerais School of Medicine, Belo Horizonte, MG, Brazil.
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25
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Mariani P, Arrigoni G, Quartierini G, Dapri G, Leone S, Barabino M, Opocher E. Local anesthesia for stapled prolapsectomy in day surgery: results of a prospective trial. Dis Colon Rectum 2005; 48:1447-50. [PMID: 15906125 DOI: 10.1007/s10350-005-0033-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This article reports the results of a prospective trial of the feasibility of Longo's procedure under local anesthesia in day surgery. METHODS From April 2002 to May 2003, 66 patients (42 males and 24 females) were enrolled in the study; the mean age was 47.5 (range, 23-65) years. Thirty-six patients (55 percent) had prolapsed third-degree hemorrhoids, while 30 (45 percent) had fourth-degree hemorrhoids. All patients were operated on under local infiltration of the anorectal region by injecting ropivacaine 7.5 mg/dl using a Quadrijet. During the surgical procedure, blood pressure and heart rate were always monitored and the level of pain was checked using a visual analog scale. Hospital discharge was programmed for 6:00 p.m. Any immediate complications, such as bleeding, urinary retention, or pain, were also recorded. RESULTS It was possible to perform the procedure under local anesthesia in all patients, and the anesthesiologist did not need to intervene at any time. No vagal reaction was observed; the transient reduction of blood pressure and heart rate, which occurred in four patients (6 percent),was controlled with an analgesic drug. In 96 percent of the cases the mean intraoperative visual analog score was not higher than four. Fifty-six patients were discharged at 6:00 p.m., while only 10 percent required an overnight stay. CONCLUSIONS The stapled prolapsectomy procedure is feasible and can be performed safely under local anesthesia and as day surgery. This procedure provides good pain control and results in a minimal number of complications.
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Affiliation(s)
- Pierpaolo Mariani
- Department of General Surgery-UCP Seriate, Bolognini Hospital, Seriate, Bergamo, Italy
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Nunoo-Mensah JW, Kaiser AM. Stapled hemorrhoidectomy. Am J Surg 2005; 190:127-30. [PMID: 15972185 DOI: 10.1016/j.amjsurg.2005.03.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2004] [Revised: 01/15/2005] [Accepted: 03/07/2005] [Indexed: 10/25/2022]
Abstract
Stapled hemorrhoidectomy has rapidly evolved and become the procedure of choice for primarily internal hemorrhoids. Even though the technique is relatively straightforward, only strict adherence to its principles will avoid serious complications and preserve the previously described benefits of this method. Recurring questions during teaching courses as well as several pitfalls that might result in suboptimal outcomes have prompted us to highlight some important details and modifications of the surgical technique.
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Affiliation(s)
- Joseph W Nunoo-Mensah
- Department of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
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Person B, Wexner SD. Novel technology and innovations in colorectal surgery: the circular stapler for treatment of hemorrhoids and fibrin glue for treatment of perianal fistulae. Surg Innov 2005; 11:241-52. [PMID: 15756393 DOI: 10.1177/155335060401100407] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The introduction of new techniques and technologies in medical science is both stimulating and controversial. This article is a review of the current status of two such advances. Since its first description, the so-called "stapled hemorrhoidectomy" has been gaining increasing popularity, at first in Asia and Europe, and more recently in the United States. It is obviously a misnomer, since no excision of hemorrhoidal tissue is undertaken in this procedure. It is probably the most significant change in the surgical treatment of hemorrhoids since the introduction of conventional hemorrhoidectomy. Patients routinely experience less postoperative pain and have excellent control of symptoms, with few serious complications in most series. Despite a relatively simple operative technique, the procedure still has specific steps and features that must be followed and mastered to help insure success. The use of fibrin glue for treatment of perianal fistulae has also been a controversial issue, thus it is seldom included in any algorithm as a therapeutic step for fistula-in-ano. The reported success rates of the treatment range from 0% to 100% owing to the heterogeneity of the clinical trials, treatment protocols, patients, etiologies, and types of fistulae. However, the benign nature, simplicity, negligible morbidity, and repeatability of the treatment, potentially makes fibrin glue an attractive first line treatment for perianal fistulae.
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Affiliation(s)
- Benjamin Person
- The Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
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Wexner SD. Recent advances in colorectal surgery. Surg Innov 2005; 11:221-4. [PMID: 15756390 DOI: 10.1177/155335060401100404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
INTRODUCTION Stapled haemorrhoidopexy is increasingly used for the surgical management of prolapsing haemorrhoids. Accurate placement of the staple line is essential to avoid involvement of the internal anal sphincter (IAS) and the pain sensitive squamous epithelium. The aim of this study was to correlate histology with symptomatic outcome after stapled haemorrhoidopexy. PATIENTS AND METHODS A single pathologist reviewed one hundred and six consecutive rectal mucosal specimens. Each specimen was assessed for the presence of columnar, transitional and squamous epithelium as well as involvement of smooth and skeletal muscle. In November 2003 all patients were sent a previously validated postal questionnaire about haemorrhoidal symptoms and a Cleveland Clinic continence scale. Symptomatic outcome was compared between patients who did or did not have squamous epithelium involvement in their pathology specimens and were analysed by Mann-Whitney U-test. RESULTS One hundred and six stapled haemorrhoidopexies were performed between June 2001 and September 2003. Eighty-four patients (79%) returned the questionnaire; 19 patients had squamous epithelium present in the pathology specimens. There was no significant difference between symptom or Cleveland Clinic scores in patients with or without squamous epithelium in their pathology specimens. Some specimens (n = 6) were found to have smooth muscle underlying squamous epithelium; this was interpreted as the presence of internal anal sphincter (IAS) within the specimen. There was no significant difference in Cleveland Clinic scores between this group and those without IAS involvement. CONCLUSION This study has not demonstrated a long-term difference in symptomatic outcome or continence in patients who have squamous epithelium present in their stapled haemorrhoidopexy specimens.
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Affiliation(s)
- V Shanmugam
- Department of Surgery, Aberdeen Royal Infirmary, Aberdeen, UK.
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Petersen S, Hellmich G, Schumann D, Schuster A, Ludwig K. Early rectal stenosis following stapled rectal mucosectomy for hemorrhoids. BMC Surg 2004; 4:6. [PMID: 15153248 PMCID: PMC420246 DOI: 10.1186/1471-2482-4-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2004] [Accepted: 05/21/2004] [Indexed: 11/10/2022] Open
Abstract
Background Within the last years, stapled rectal mucosectomy (SRM) has become a widely accepted procedure for second and third degree hemorrhoids. One of the delayed complications is a stenosis of the lower rectum. In order to evaluate the specific problem of rectal stenosis following SRM we reviewed our data with special respect to potential predictive factors or stenotic events. Methods A retrospective analysis of 419 consecutive patients, which underwent SRM from December 1998 to August 2003 was performed. Only patients with at least one follow-up check were evaluated, thus the analysis includes 289 patients with a mean follow-up of 281 days (±18 days). For statistic analysis the groups with and without stenosis were evaluated using the Chi-Square Test, using the Kaplan-Meier statistic the actuarial incidence for rectal stenosis was plotted. Results Rectal stenosis was observed in 9 patients (3.1%), eight of these stenoses were detected within the first 100 days after surgery; the median time to stenosis was 95 days. Only one patient had a rectal stenosis after more than one year. 8 of the 9 patients had no obstructive symptoms, however the remaining patients complained of obstructive defecation and underwent surgery for transanal strictureplasty with electrocautery. A statistical analysis revealed that patients with stenosis had significantly more often prior treatment for hemorrhoids (p < 0.01). According to the SRM only severe postoperative pain was significantly associated with stenoses (p < 0.01). Other factors, such as gender (p = 0.11), surgical technique (p = 0.25), revision (p = 0.79) or histological evidence of squamous skin (p = 0.69) showed no significance. Conclusion Rectal stenosis is an uncommon event after SRM. Early stenosis will occur within the first three months after surgery. The majority of the stenoses are without clinical relevance. Only one of nine patients had to undergo surgery for a relevant stenosis. The predictive factor for stenosis in the patient-characteristics is previous interventions for hemorrhoids, severe postoperative pain might also predict rectal stenosis.
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Affiliation(s)
- Sven Petersen
- Department of General- and Abdominal Surgery, General Hospital Dresden-Friedrichstadt, Teaching Hospital Technical University of Dresden, Dresden Germany
| | - Gunter Hellmich
- Department of General- and Abdominal Surgery, General Hospital Dresden-Friedrichstadt, Teaching Hospital Technical University of Dresden, Dresden Germany
| | - Dietrich Schumann
- Department of General- and Abdominal Surgery, General Hospital Dresden-Friedrichstadt, Teaching Hospital Technical University of Dresden, Dresden Germany
| | - Anja Schuster
- Department of General- and Abdominal Surgery, General Hospital Dresden-Friedrichstadt, Teaching Hospital Technical University of Dresden, Dresden Germany
| | - Klaus Ludwig
- Department of General- and Abdominal Surgery, General Hospital Dresden-Friedrichstadt, Teaching Hospital Technical University of Dresden, Dresden Germany
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Abstract
Stapled hemorrhoidopexy is a new procedure for the treatment of symptomatic internal hemorrhoids. Experience and prospective trials are helping to define this procedure's role. Published data confirm that stapled hemorrhoidopexy offers similar control of symptoms with the benefits of reduced postoperative pain when compared with excisional techniques. Reduction in pain is the most significant benefit of this operation. Clearly, the cost of the stapling device exceeds the cost of the sutures required to perform an excisional hemorrhoidectomy. Patients should undergo medical therapy and rubber band ligation first; however, patients being considered for excisional hemorrhoidectomy should be offered stapled hemorrhoidectomy as a less painful alternative.
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Affiliation(s)
- Marc Singer
- Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Herand Abcarian
- Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
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Abstract
BACKGROUND Conventional pathogenesis of haemorrhoid emphasized the anchoring connective tissue system, whereas the vascular changes were ignored. The aim of this study was to clarify vascular changes of haemorrhoid disease. MATERIALS AND METHODS Forty-six samples of grade III and grade IV haemorrhoid tissue were selected for an in vitro study. We assessed the expressions in endoglin (CD105), an accessory protein in transforming growth factor-beta receptor complex, in CD34 and in vascular endothelial growth factor by using an immunohistochemical method. Microvascular density was calculated to correlate the expression of endoglin. RESULTS Microvascular density was higher in haemorrhoid tissue than in normal anal and lower rectal tissues. CD34 was demonstrated in whole vessels in the haemorrhoids. However, endoglin, a proliferative marker of neovascularization, was present in only 25 of 46 (54%) haemorrhoidal vessels, and its immunoactivity was prominent in venules larger than 100 micro m. Thrombosis formation and stromal vascular endothelial growth factor was significantly associated with the presence of endoglin immunoactivity. CONCLUSION The results of this study suggest that neovascularization is one important phenomenon of haemorrhoid disease, along with conventional venous dilatation and arteriovenous communication. In addition, thrombosis and stromal vascular endothelial growth factor might be important factors in promoting vascular proliferation.
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Pérez-Vicente F, Arroyo A, Candela F, Serrano P, Sánchez-Romero A, Costa D, Fernández-Frías A, Oliver I, Rodríguez-Hidalgo JM, Calpena R. Importancia de la curva de aprendizaje de la anopexia con PPH-33 para el tratamiento quirúrgico de las hemorroides. Cir Esp 2004. [DOI: 10.1016/s0009-739x(04)72349-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Luis Hidalgo-Grau A, Heredia-Budó A, García-Cuyàs F, Maria Gubern-Nogués J, Suñol-Sala X. Anopexia mucosa circular en el tratamiento de las hemorroides y del prolapso mucoso rectal: complicaciones y resultados. Cir Esp 2004. [DOI: 10.1016/s0009-739x(04)72364-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Dixon MR, Stamos MJ, Grant SR, Kumar RR, Ko CY, Williams RA, Arnell TD. Stapled Hemorrhoidectomy: A Review of Our Early Experience. Am Surg 2003. [DOI: 10.1177/000313480306901009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Treatment of hemorrhoids may safely be accomplished by using a circular stapler instead of the conventional open procedure for large symptomatic hemorrhoids. Our purpose was to assess the safety and early post-op results of this new surgical technique as it was introduced into clinical practice. Medical records from 62 patients treated by circumferential mucosectomy/stapled hemorrhoidectomy were obtained from 6 surgeons. Preoperative factors assessed included demographics, comorbidities, prior anorectal surgery, hemorrhoid grade, and the indications for surgery. Operative factors examined included operating time, use of perioperative antibiotics, and oversewing of the suture line. Postoperative factors included complications and date of last follow-up. Sixty-two patients underwent this operation, and complications were reported in six patients (10%). There was one death unrelated to the hemorrhoid surgery. Postoperative pain, defined as requiring pain control with intravenous medication, hospital admission, or an emergency department visit, occurred in two patients. Two patients reported postoperative bleeding. One patient experienced bleeding the first evening, and the second patient had bleeding 1 week postoperatively. The first patient was admitted overnight and required no blood transfusion or further intervention. The second patient was subsequently found to have a bleeding diverticulum. One patient experienced urinary retention that resolved with conservative management. Postoperative follow-up was available for over 90 per cent of the patients at a median of 4 weeks postoperatively. No additional complications were discovered at follow-up. This data suggests that stapled hemorrhoidectomy is a safe and effective approach to hemorrhoidal disease. Our findings indicate an acceptable complication rate among a group of surgeons beginning to integrate this modality into clinical practice.
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Affiliation(s)
- Matthew R. Dixon
- From theDepartment of Surgery, Division of Colorectal Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Michael J. Stamos
- Department of Surgery, Division of Colorectal Surgery, University of California-Irvine Medical Center
| | | | - Ravin R. Kumar
- From theDepartment of Surgery, Division of Colorectal Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Clifford Y. Ko
- VAMC Greater Los Angeles Healthcare System, West Los Angeles, California, UCLA Medical Center, Los Angeles, California
| | - Russell A. Williams
- Department of Surgery, Division of Colorectal Surgery, University of California-Irvine Medical Center
| | - Tracey D. Arnell
- Department of Surgery, Division of Colorectal Surgery, Columbia-Presbyterian Medical Center, New York, New York
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Abstract
Hemorrhoids remain one of the most common colorectal complaints. They are defined as a pathologic engorgement of the submucosal vascular plexus. Although they are often asymptomatic, hemorrhoids may cause bleeding, prolapse and, less commonly, pain. This review gives an update on various treatment options for symptomatic hemorrhoids, which include conservative treatments, office interventions, and surgical procedures, depending on the individual constellation of symptoms. Objective findings and expectations are also addressed. Recent advances (eg, stapled hemorrhoidectomy and use of alternate energy sources) are emphasized, and treatment under special circumstances (HIV, pregnancy, inflammatory bowel disease, and liver disease) is outlined.
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Affiliation(s)
- Swarna Balasubramaniam
- Department of Colorectal Surgery, Keck School of Medicine, University of Southern California, 1450 San Pablo Street, Suite 5400, Los Angeles, CA 90033, USA.
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Corman ML, Gravié JF, Hager T, Loudon MA, Mascagni D, Nyström PO, Seow-Choen F, Abcarian H, Marcello P, Weiss E, Longo A. Stapled haemorrhoidopexy: a consensus position paper by an international working party - indications, contra-indications and technique. Colorectal Dis 2003; 5:304-10. [PMID: 12814406 DOI: 10.1046/j.1463-1318.2003.00483.x] [Citation(s) in RCA: 102] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
An international working party with experience in the performance of an alternative haemorrhoid operation through the use of the circular stapler was convened for the purpose of developing a consensus as to the criteria for undertaking this procedure. The agenda consisted of first, naming the operation; second, the indications and contra-indications for its performance; and third, the preferred surgical technique. Among the recommendations for individuals who plan to embark on this surgery are that experience with anorectal surgery and an understanding of anorectal anatomy are requisites; experience with circular stapling devices is essential; and the surgeon must attend a formal course which should include lectures, videos, the application of the instrument in models, and observation of the operation as performed by a surgeon recognized by his or her peers-leading ultimately to undertaking the procedure while being observed by an experienced surgeon. Following satisfactory completion of the above, independent responsibility should be determined by an individual's department of surgery.
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Affiliation(s)
- M L Corman
- Department of Surgery, North Shore-Long Island Jewish Medical Center, NewHyde Park, New York 11040, USA.
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Affiliation(s)
- Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL 33331, USA
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Roig Vila JV. Anopexia grapada. ¿Un antes y un después en el tratamiento de las hemorroides prolapsadas? Cir Esp 2002. [DOI: 10.1016/s0009-739x(02)72064-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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