1
|
Hidalgo-Grau LA, Piedrafita-Serra E, Ruiz-Edo N, Llorca-Cardeñosa S, Heredia-Budó A, Estrada-Ferrer O, Suñol-Sala X. Prospective Randomized Study on Stapled Anopexy Height and Its Influence on Recurrence for Hemorrhoidal Disease Treatment. World J Surg 2020; 44:3936-3942. [PMID: 32647985 DOI: 10.1007/s00268-020-05676-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To know the influence of the stapled line height (SLH) in the recurrence rate and the postoperative disturbances in stapled anopexy (SA) for the treatment of hemorrhoids. DESIGN Simple randomized double-blind controlled clinical trial. Randomization with closed-envelope technique in two groups with two different SLH. SETTING Colorectal Surgery Unit. Department of General Surgery. Hospital de Mataró (Barcelona, Spain). PARTICIPANTS 119 patients with the diagnosis of symptomatic third- and fourth-grade hemorrhoids were included. INTERVENTION SA was performed with two different SLH: group A, 4.5 cm (58 patients) and group B, 6 cm (61 patients) from the external anal verge. Postoperative disturbances were evaluated by a colorectal surgeon who was blind for the randomization and pain was measured (visual analogic scale) one week and 3 months after surgery. Mean operative time, number of hemostatic stitches performed and resected mucosal area were considered as well. Mean follow-up was 11.05 ± 1.6 years. RESULTS Differences between the operative time and resected mucosa-submucosa area were not found. The patients of group A needed a significantly higher number of stitches for intraoperative bleeding control along the stapled line. We did not found differences between both groups in terms of postoperative pain neither anorectal disturbances. At the follow-up, persistence of symptomatology was 10.41% in group A and 10.71% in group B, without statistically significance. Neither mortality nor undesirable effects occurred in the series. CONCLUSIONS SLH do not influence the recurrence rate neither the postoperative evolution in SA. TRIAL REGISTRATION Clinical Trials NCT03383926.
Collapse
Affiliation(s)
| | - Encarna Piedrafita-Serra
- Colorectal Surgery Unit, Department of General and Digestive, Hospital de Mataró, Barcelona, Spain. .,Department of Surgery and Morphological Sciences, Universitat Autónoma de Barcelona, Barcelona, Spain.
| | - Neus Ruiz-Edo
- Colorectal Surgery Unit, Department of General and Digestive, Hospital de Mataró, Barcelona, Spain
| | - Sara Llorca-Cardeñosa
- Colorectal Surgery Unit, Department of General and Digestive, Hospital de Mataró, Barcelona, Spain
| | - Adolfo Heredia-Budó
- Colorectal Surgery Unit, Department of General and Digestive, Hospital de Mataró, Barcelona, Spain
| | - Oscar Estrada-Ferrer
- Colorectal Surgery Unit, Department of General and Digestive, Hospital de Mataró, Barcelona, Spain
| | - Xavier Suñol-Sala
- Colorectal Surgery Unit, Department of General and Digestive, Hospital de Mataró, Barcelona, Spain
| |
Collapse
|
2
|
Hidalgo Grau LA, Ruiz Edo N, Llorca Cardeñosa S, Heredia Budó A, Estrada Ferrer Ó, Del Bas Rubia M, García Torralbo EM, Suñol Sala X. Circular mucosal anopexy: Experience and technical considerations. Cir Esp 2016; 94:287-93. [PMID: 26997121 DOI: 10.1016/j.ciresp.2015.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 11/12/2015] [Accepted: 12/19/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Circular mucosal anopexy (CMA) achieves a more comfortable postoperative period than resective techniques. But complications and recurrences are not infrequent. This study aims to evaluate of the efficacy of CMA in the treatment of hemorrhoids and rectal mucosal prolapse (RMP). METHOD From 1999 to 2011, 613 patients underwent surgery for either hemorrhoids or RMP in our hospital. CMA was performed in 327 patients. Gender distribution was 196 male and 131 female. Hemorrhoidal grades were distributed as follows: 28 patients had RMP, 46 2nd grade, 146 3rd grade and 107 4th grade. Major ambulatory surgery (MAS) was performed in 79.9%. Recurrence of hemorrhoids was studied and groups of recurrence and no-recurrence were compared. Postoperative pain was evaluated by Visual Analogical Scale (VAS) as well as early complications. RESULTS A total of 31 patients needed reoperation (5 RMP, 2 with 2nd grade, 17 with 3rd grade,/with 4th grade). No statistically significant differences were found between the non-recurrent group and the recurrent group with regards to gender, surgical time or hemorrhoidal grade, but there were differences related to age. In the VAS, 81.3% of patients expressed a postoperative pain ≤ 2 at the first week. Five patients needed reoperation for early postoperative bleeding. Six patients needed admission for postoperative pain. CONCLUSIONS Recurrence rate is higher in CMA than in resective techniques. CMA is a useful technique for the treatment of hemorrhoids in MAS. Pain and the rate of complications are both low.
Collapse
Affiliation(s)
- Luis Antonio Hidalgo Grau
- Servicio de Cirugía General y del Aparato Digestivo, Unidad de Cirugía Colorrectal, Hospital de Mataró, Mataró (Barcelona), España
| | - Neus Ruiz Edo
- Servicio de Cirugía General y del Aparato Digestivo, Unidad de Cirugía Colorrectal, Hospital de Mataró, Mataró (Barcelona), España.
| | - Sara Llorca Cardeñosa
- Servicio de Cirugía General y del Aparato Digestivo, Unidad de Cirugía Colorrectal, Hospital de Mataró, Mataró (Barcelona), España
| | - Adolfo Heredia Budó
- Servicio de Cirugía General y del Aparato Digestivo, Unidad de Cirugía Colorrectal, Hospital de Mataró, Mataró (Barcelona), España
| | - Óscar Estrada Ferrer
- Servicio de Cirugía General y del Aparato Digestivo, Unidad de Cirugía Colorrectal, Hospital de Mataró, Mataró (Barcelona), España
| | - Marta Del Bas Rubia
- Servicio de Cirugía General y del Aparato Digestivo, Unidad de Cirugía Colorrectal, Hospital de Mataró, Mataró (Barcelona), España
| | - Eva María García Torralbo
- Servicio de Cirugía General y del Aparato Digestivo, Unidad de Cirugía Colorrectal, Hospital de Mataró, Mataró (Barcelona), España
| | - Xavier Suñol Sala
- Servicio de Cirugía General y del Aparato Digestivo, Unidad de Cirugía Colorrectal, Hospital de Mataró, Mataró (Barcelona), España
| |
Collapse
|
3
|
Kajbafzadeh AM, Kajbafzadeh M, Sabetkish S, Sabetkish N, Tavangar SM. Tissue-Engineered External Anal Sphincter Using Autologous Myogenic Satellite Cells and Extracellular Matrix: Functional and Histological Studies. Ann Biomed Eng 2015; 44:1773-84. [PMID: 26424474 DOI: 10.1007/s10439-015-1468-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Accepted: 09/22/2015] [Indexed: 02/06/2023]
Abstract
The aim of the present study was to demonstrate the regaining histological characteristics of bioengineered external anal sphincters (EAS) in rabbit fecal incontinence model. The EAS of 16 rabbits were resected and decellularized. The decellularized scaffolds were transplanted to the terminal rectum following a period of 6 months of fecal incontinency (5 days after sterilization). The rabbits were divided into two groups: in group 1 (n = 8), myogenic satellite cells were injected into the transplanted sphincters. In group 2 (n = 8), the transplanted scaffolds remained in situ without cellular injection. The histological evaluation was performed with desmin, myosin, smooth muscle actin, CD31, and CD34 at 3-month intervals. The rabbits were followed for 2 years. Electromyography (EMG) with needle and electrical stimulation, pudendal and muscle electrical stimulation were also performed after 2 years of transplantation. At the time of biopsy, no evidence of inflammation or rejection was observed and the transplanted EAS appeared histologically and anatomically normal. The immunohistochemistry staining validated that the histological features of EAS was more satisfactory in group 1 in short-term follow-up. However, no statistically significant difference was detected between two groups in long-term follow-ups (p value > 0.05). In both groups, grafted EAS contracted in response to electrical signals delivered to the muscle and the pudendal nerve. However, more signals were detected in group 1 in EMG evaluation. In conclusion, bioengineered EAS with myogenic satellite cells can gain more satisfactory histological outcomes in short-term follow-ups with better muscle electrical stimulation outcomes.
Collapse
Affiliation(s)
- Abdol-Mohammad Kajbafzadeh
- Pediatric Urology Research Center, Section of Tissue Engineering and Stem Cells Therapy, Children's Hospital Medical Center, Tehran University of Medical Sciences, No. 62, Dr. Qarib's Street, Keshavarz Boulevard, Tehran, 1419433151, Islamic Republic of Iran.
| | - Majid Kajbafzadeh
- Sydney Medical School, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Shabnam Sabetkish
- Pediatric Urology Research Center, Section of Tissue Engineering and Stem Cells Therapy, Children's Hospital Medical Center, Tehran University of Medical Sciences, No. 62, Dr. Qarib's Street, Keshavarz Boulevard, Tehran, 1419433151, Islamic Republic of Iran
| | - Nastaran Sabetkish
- Pediatric Urology Research Center, Section of Tissue Engineering and Stem Cells Therapy, Children's Hospital Medical Center, Tehran University of Medical Sciences, No. 62, Dr. Qarib's Street, Keshavarz Boulevard, Tehran, 1419433151, Islamic Republic of Iran
| | - Seyyed Mohammad Tavangar
- Department of Pathology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
| |
Collapse
|
4
|
Does the removal of retained staples really improve postoperative chronic sequelae after transanal stapled operations? Dis Colon Rectum 2014; 57:658-62. [PMID: 24819108 DOI: 10.1097/dcr.0000000000000024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Transanal stapled procedures are increasingly being used. Several postoperative complications can be referred to their application, including those related to the presence of retained staples at the level of the staple line. OBJECTIVE This study was conducted to assess whether the removal of the retained staples is a useful approach to improve some of the most common postoperative complications of these surgical techniques. DESIGN This is a retrospective study. SETTINGS The study was conducted at the One-Day Surgery Unit of St. Andrea Hospital. PATIENTS All of the patients who underwent a stapled transanal procedure from January 2003 to December 2011 were included in the study. Patients included in the study were followed postoperatively for 1 year after surgery to identify the presence of retained staples. INTERVENTIONS If identified, the retained staples were removed endoscopically or transanally. MAIN OUTCOME MEASURES After the staple removal, patients were followed with biweekly office visit for 2 months to evaluate the progression of symptoms. RESULTS From the 566 patients included in the study, 165 experienced postoperative complications, and in 66 of these cases, retained staples were found and removed. With the removal of retained staples, symptoms were almost all resolved or improved. In only 1 case did the retained staples removal not modify the symptoms. LIMITATIONS The study design may have introduced potential selection bias. In addition, the study was limited by the lack of a specific questionnaire for the evaluation of symptoms improvement. CONCLUSIONS The removal of the retained staples is an efficacious and safe procedure to solve or improve postoperative complications and should be always considered.
Collapse
|
5
|
Kim DS. Histopathology and physiological alterations after procedure for prolapsed hemorrhoids. Ann Coloproctol 2013; 29:179-80. [PMID: 24278853 PMCID: PMC3837080 DOI: 10.3393/ac.2013.29.5.179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Affiliation(s)
- Do Sun Kim
- Department of Surgery, Daehang Hospital, Seoul, Korea
| |
Collapse
|
6
|
Hong YK, Choi YJ, Kang JG. Correlation of histopathology with anorectal manometry following stapled hemorrhoidopexy. Ann Coloproctol 2013; 29:198-204. [PMID: 24278858 PMCID: PMC3837085 DOI: 10.3393/ac.2013.29.5.198] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2013] [Accepted: 05/14/2013] [Indexed: 02/04/2023] Open
Abstract
Purpose The removal of smooth muscle during stapled hemorrhoidopexy raises concerns regarding its effects on postoperative anorectal function. The purpose of this study was to evaluate the correlation between the amount of muscle removed and changes in anorectal manometry following stapled hemorrhoidopexy. Methods Patients with symptomatic II, III, or IV degree hemorrhoids that underwent stapled hemorrhoidopexy between January 2008 and May 2011 were included in this study. Anorectal manometry was performed preoperatively and at three months postoperatively. The resected doughnuts were examined histologically, and the thicknesses of muscle fibers were evaluated. Results Eighty-five patients (34 males) with a median age of 47 years were included. Muscularis propria fibers were identified in 63 of 85 pathologic specimens (74.1%). The median thickness of the muscle fibers was 1.58 ± 1.21 mm (0 to 4.5 mm). The mean resting pressure decreased by approximately 7 mmHg after operation in the 85 patients (P = 0.019). In patients with muscle incorporation, there was a significant difference in mean resting pressure (P = 0.041). In the analysis of the correlation of the difference in anorectal manometry results ([the result of postsurgical anorectal manometry] - [the result of presurgical anorectal manometry]) to the thickness of muscle fibers, no significant differences were seen. No patients presented with fecal incontinence. Conclusion Although the incidence of fecal incontinence is very low, muscle incorporation in the resected doughnuts following stapled hemorrhoidopexy may affect anorectal pressure. Therefore, surgeons should endeavor to minimize internal sphincter injury during stapled hemorrhoidopexy.
Collapse
Affiliation(s)
- Young Ki Hong
- Department of Surgery, National Health Insurance Corporation Ilsan Hospital, Goyang, Korea
| | | | | |
Collapse
|
7
|
Stapled hemorrhoidopexy versus Milligan-Morgan hemorrhoidectomy in circumferential third-degree hemorrhoids: long-term results of a randomized controlled trial. J Gastrointest Surg 2013; 17:1292-8. [PMID: 23670518 DOI: 10.1007/s11605-013-2220-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Accepted: 04/24/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND The literature indicates higher recurrence rates for stapled hemorrhoidopexy than for conventional techniques. This could be due to inappropriate patient selection. OBJECTIVE The aim of this study was to evaluate the short- and long-term outcome after stapled hemorrhoidopexy compared with the Milligan-Morgan procedure in a homogeneous patient population with circumferential third-degree hemorrhoids. DESIGN AND PATIENTS One hundred thirty patients were enrolled into a randomized controlled study, of which 122 were clinically evaluated at weeks 1, 2, and 4, and thereafter each year for a minimum of 3 years. Patients completed a questionnaire for symptoms, function, and pain. Pain was assessed using a visual analog scale. Recurrences were determined by anoscopy and self-report. SETTINGS The study was performed at the University Hospital Hamburg. MAIN OUTCOME MEASURES Endpoints were pain, recurrence, bleeding, itching/burning, urinary retention, incontinence symptoms, and prolonged rate of wound healing. RESULTS The cumulative recurrence rates after 5 years were 18 % (n = 11) in the stapled hemorrhoidopexy group and 23 % (n = 14) in the Milligan-Morgan group (p = 0.65). Patients who underwent stapled hemorrhoidopexy had significantly less postoperative pain with mean VAS scores at week 1: 3.1 vs. 6.2; week 2: 0.5 vs. 3; week 4: 0.05 vs. 0.6 (p < 0.001), and demonstrated less burning/itching sensation 4 weeks after surgery compared with the Milligan-Morgan group (4.9 vs. 19.7 %; p < 0.001). The postoperative bleeding rate was 4.9 % in both groups and the rate of urinary retention did not differ significantly (4.9 % vs. 1.6 %; p = 0.309). Postoperative incontinence symptoms (6.6 % versus 3.3 %; p = 0.40) resolved within the first 6 months. LIMITATIONS Detailed measurement of incontinence was not possible because postoperative symptoms resolved between consultations, and pathological results were examined retrospectively. CONCLUSIONS The results show a similar rate of recurrence in the long term and suggest increased patient comfort in the early postoperative course after stapled hemorrhoidopexy. In patients with circumferential third-degree hemorrhoids, stapled hemorrhoidopexy is as effective as the Milligan-Morgan procedure.
Collapse
|
8
|
Agraffectomy after low rectal stapling procedures for hemorrhoids and rectocele. Tech Coloproctol 2011; 15:259-64. [PMID: 21695440 DOI: 10.1007/s10151-011-0704-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Accepted: 06/07/2011] [Indexed: 12/26/2022]
Abstract
BACKGROUND Various sequelae which might lead to reintervention have been described after stapled rectal mucosectomy for hemorrhoids. One potential treatment modality for persistent complaints after stapled hemorrhoidopexy (SHP) or stapling for rectocele is the so-called agraffectomy (removal of the retained staples). This treatment option means a further procedure that can range from removal of the staples through the anoscope to removal of the entire staple line with the associated scar tissue. METHODS In order to review the published literature, we conducted a search on Medline, Pubmed, and Embase using different terms for "agraffectomy." RESULTS Overall, fourteen reports were found, dealing with agraffectomy for various conditions after low rectal stapling for hemorrhoids or rectocele. Agraffectomy is a rarely mentioned treatment option for conditions after SHP. In rectal stenosis with complete occlusion of the rectal lumen, the removal of the stenotic anastomosis and remaining staples seems to be reasonable. The same can be said of the removal of retained staples for rectal bleeding or in order to avoid penile injuries in anal intercourse. In contrast, the collected published reports on agraffectomy in this review only provide low-level evidence that this procedure provides relief for other problems such as incontinence or chronic pain. CONCLUSIONS There is no clear evidence that agraffectomy is indicated if not in case of rectal stenosis and hemorrhage caused by the staples.
Collapse
|
9
|
Calomino N, Martellucci J, Fontani A, Papi F, Cetta F, Tanzini G. Care with regard to details improves the outcome of Longo mucoprolapsectomy: long term follow up. Updates Surg 2011; 63:151-4. [PMID: 21604057 DOI: 10.1007/s13304-011-0077-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2011] [Accepted: 04/23/2011] [Indexed: 10/18/2022]
Abstract
In this study we evaluated the results of stapled hemorrhoidopexy considering the histological features of the resected tissue obtained after the intervention, the staple line height and the improvement of the quality of life after the treatment. From January 2003 to December 2006, 72 patients with symptomatic grade 3 and 4 hemorrhoid that underwent stapled hemorrhoidopexy in our clinic were enroled in the study. Preoperative, intraoperative and postoperative characteristics of the patients were evaluated, including demographics, staple line height, specimen histology, complications, recurrence, day to return to work, quality of life (QoL) score and use of analgesics. Staple line height was always above 2.5 cm from the dentate line. Smooth muscle fibers were observed in 97.2%. The complication rate was 18%. Bleeding was observed in 5.5%. Fecal urgency was referred in 6.9%. Recurrence rate was 6.9%. Mean follow-up was 68 months. Hemorrhoidopexy is safe and effective but extreme attention must be paid to some critical details. We consider the placement of the purse string suture as a critical factor in the outcome of the patients. We find that some amount of the muscle fibers would invariably be involved in the resected specimen, without any significant impact in the clinical outcome or in the quality of life improvement.
Collapse
Affiliation(s)
- Natale Calomino
- General Surgery I, Ospedale Le Scotte, University of Siena, viale Bracci 1, 53100, Siena, Italy
| | | | | | | | | | | |
Collapse
|
10
|
Filho FLA, Macedo GM, Dos Santos AA, Rodrigues LV, Oliveira RB, Nobre E Souza MA. Stapled haemorrhoidopexy transiently decreases rectal compliance and sensitivity. Colorectal Dis 2011; 13:219-24. [PMID: 19888951 DOI: 10.1111/j.1463-1318.2009.02103.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Stapled haemorrhoidopexy may damage the anorectal musculature and its sensorimotor function. Most studies have not used a barostat for the measurement of compliance. This study aimed to investigate the effect of stapled haemorrhoidopexy on rectal compliance and sensitivity. METHOD After Ethical Committee approval, we studied 10 male patients (mean age 33.8 years) with third- or fourth-degree haemorrhoids. Rectal compliance and sensitivity were measured with a 600-ml bag and an electronic barostat. Volunteers were submitted to two consecutive rectal distension protocols, including continuous distension at 2, 4 and 6 months after stapled haemorrhoidopexy. Intraluminal volume and pressure were recorded, including the first rectal sensation, desire to defecate and onset of rectal pain. Another group of 10 male control patients (mean age 24.9 years) with pilonidal sinus and no haemorrhoids was also included in the study. RESULTS Two months after stapled haemorrhoidopexy, rectal compliance decreased (7.1 ± 0.2 vs 5.3 ± 0.1, 6.4 ± 0.1 vs 5.1 ± 0.1 and 5.6 ± 0.2 vs 4.7 ± 0.1 ml/mmHg for first rectal sensation, desire to defecate and rectal pain, respectively; P < 0.05). The sensitivity threshold volume did not change for the first sensation but decreased significantly for the desier to defecate and pain (p <0.05) (116.8 ± 13.8 vs 148.4 ± 14.61, 251.1 ± 8.9 vs 185.8 ± 8.6 and 293.3 ± 16.6 vs 221.2 ± 6.0 ml for first rectal sensation, desire to defecate and rectal pain, respectively). Four and 6 months after surgery, rectal compliance and sensitivity returned to levels similar to those in the basal period. Muscle tissue was found in only three of the 10 resected doughnuts. Controls remained without any change in rectal compliance and sensitivity. CONCLUSION Stapled haemorrhoidopexy transiently decreases rectal compliance and sensitivity threshold in young male patients.
Collapse
Affiliation(s)
- F L A Filho
- Departments of Surgery Physiology and Pharmacology and Clinical Medicine, School of Medicine, Federal University of Ceará, Fortaleza, Brazil
| | | | | | | | | | | |
Collapse
|
11
|
Functional external anal sphincter reconstruction for treatment of anal incontinence using muscle progenitor cell auto grafting. Dis Colon Rectum 2010; 53:1415-21. [PMID: 20847624 DOI: 10.1007/dcr.0b013e3181e53088] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This study aimed to investigate the feasibility of autologous muscle progenitor cell transplantation for anal sphincter regeneration in a rabbit model of anal incontinence. We examined the serial changes in structure, with particular emphasis on histology and functional properties of the anal sphincter. METHODS External anal sphincterotomy was performed in 21 rabbits; these rabbits were randomly assigned to 2 groups. In group I (n = 9), autologous muscle progenitor cells were isolated from quadriceps myofiber explants, labeled with PKH-26, and injected into sphincter 3 weeks after sphincterotomy. In group II (n = 12), saline buffer was injected at the site of damage. Sphincter electromyography and manometry were performed immediately before sphincterotomy and 14, 28, and 60 days after injection in 3 animals in each group at every interval and the findings were correlated with histomorphological studies. In addition, electromyography and manometry were performed in the remaining 3 rabbits in group II after 6 months. RESULTS In group II, a flaccid sphincter persisted during the 6 months of follow-up. In group I, muscle progenitor autografting accelerated sphincter myofiber repair and improvement in functional capacity of the damaged sphincter. Fluorescently labeled cells were detected in all of the grafted sphincters; regenerated myotubes were detectable at the injection site as evidenced by the presence of desmin. We also observed a significant decrease in interstitial fibrosis in the 4th week and strikingly higher amounts of Ki-67-positive cells in group I. Manometry and electromyography showed a significant improvement in the mean resting anal canal pressure and sphincteric electrical activity 4 weeks after cell injection, respectively. CONCLUSION Transplanting muscle progenitor cells showed the potential for recapitulation of a myogenic program when injected into deficient rabbit anal sphincter. Objective anal measures of resting and stimulated pressures and electromyographic profile improved. Stem cell-mediated anal myoplasty warrants additional investigation as a new method to treat anal incontinence before attempting this modality in the clinical setting.
Collapse
|
12
|
Kam MH, Ng KH, Lim JF, Ho KS, Ooi BS, Tang CL, Eu KW. Results of 7302 stapled haemorrhoidectomy operations in a single centre: a seven-year review and follow-up questionnaire survey. ANZ J Surg 2010; 81:253-6. [PMID: 21418468 DOI: 10.1111/j.1445-2197.2010.05478.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND This study aims to evaluate the results of all 7302 stapled haemorrhoidectomy operations performed in a single centre. METHOD A retrospective review of all 7302 patients who underwent stapled haemorrhoidectomy at our department over seven years was conducted. The hospital database was reviewed for subsequent readmissions and re-operations. A questionnaire survey was also sent out to all the patients. RESULTS A total of 302 patients (4.1%) were admitted with post-operative bleeding and 281 stopped with conservative measures. Twenty one required surgical haemostasis. A total of 301 patients (4.1%) were admitted for an inability to void and 191 (2.6%) had true acute retention of urine, requiring catheterization. There were 124 patients (1.7%) admitted for pain, but all resolved with oral analgesia subsequently. Anal stricture requiring surgery occurred in only 86 patients (1.2%). Serious complications such as staple line dehiscence or anorectal sepsis occurred in seven patients. There were a total of 14 recurrences requiring readmission over this seven-year period, of which 12 were treated successfully with a second haemorrhoidectomy. A total of 1834 patients returned their questionnaire surveys and 95% of the patients reported complete resolution or improvement of their symptoms. Only 27 patients reported subsequent severe bleeding requiring medical attention. CONCLUSION Stapled haemorrhoidectomy is safe, and most patients are satisfied with the long-term outcome.
Collapse
Affiliation(s)
- Ming-Hian Kam
- Department of Colorectal Surgery, Singapore General Hospital, Singapore
| | | | | | | | | | | | | |
Collapse
|
13
|
Shanmugam V, Muthukumarasamy G, Cook JA, Vale L, Watson AJM, Loudon MA. Randomized controlled trial comparing rubber band ligation with stapled haemorrhoidopexy for Grade II circumferential haemorrhoids: long-term results. Colorectal Dis 2010; 12:579-86. [PMID: 19508542 DOI: 10.1111/j.1463-1318.2009.01841.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE An improved understanding of the pathophysiology of haemorrhoids has resulted in the introduction of new surgical techniques including stapled haemorrhoidopexy (SH). This randomized controlled trial compared the long-term effectiveness of SH with rubber band ligation (RBL) in the treatment of grade II circumferential symptomatic haemorrhoids. METHOD A consecutive cohort of patients was randomly allocated to either SH or RBL. Data on haemorrhoidal symptoms, Cleveland continence scores, sphincter assessment, SF-36, EQ-5D, HAD score and prior treatment history were assessed at enrollment and reassessed by long-term postal questionnaire. The details were analysed using spss 12.0 from Microsoft Access. RESULTS Sixty patients were allocated by computer block randomization. Both groups were balanced for age, sex and symptoms. Recurrence favoured SH [3 vs 11; OR 0.18, 95% CI (0.03 to 0.86), P = 0.028] at 1 year and, at a mean of 40.67 (31-47) months [4 vs 12; OR 0.23, 95% CI (0.05, 0.95); P = 0.039]. SH patients experienced prolonged pain [Median (IQR) = 7 (5,7) vs 3 (1,7), P = 0.008] and took a longer time to return to work [6 (3,7) vs 3 (1,6) days, P = 0.018]. This was no significant difference in quality of life. CONCLUSION Stapled haemorrhoidopexy achieved better disease control at 1 year without any major complication. This was sustained in the long-term. Further studies with greater patient numbers are needed to confirm this study.
Collapse
Affiliation(s)
- V Shanmugam
- Department of Surgery, Queens Medical Centre, Aberdeen Royal Infirmary, University of Aberdeen, Scotland.
| | | | | | | | | | | |
Collapse
|
14
|
Rectal distensibility and symptoms after stapled and Milligan-Morgan operation for hemorrhoids. J Gastrointest Surg 2009; 13:2245-51. [PMID: 19672663 DOI: 10.1007/s11605-009-0983-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2009] [Accepted: 07/24/2009] [Indexed: 01/31/2023]
Abstract
INTRODUCTION In a previous uncontrolled study, a reduction of rectal distensibility and volume thresholds for sensations have been related to the occurrence of fecal urgency and/or increased stool frequency after stapled hemorrhoidopexy. AIM OF THE STUDY The aim of this study was to compare rectal symptoms and sensory-motor function after stapled hemorrhoidopexy and Milligan-Morgan hemorrhoidectomy. METHODS The clinical records of 12 (four women) and ten patients (four women) with third- and fourth-degree hemorrhoids, respectively, who underwent stapled hemorrhoidopexy or Milligan-Morgan's hemorrhoidectomy, were evaluated. One week before and 6 months after surgery, rectal motor and sensory response to distension was assessed by an electronic barostat, and bowel and rectal symptoms were recorded by means of a 7-day diary and Bristol Index scale and psychological symptoms with SCL-90 questionnaire. RESULTS Rectal distensibility and volume thresholds for sensations were significantly lower after surgery (P < 0.02) in the stapled group. Increased stool frequency and/or fecal urgency arose in 41% of patients in the stapled group and associated with altered rectal distensibility. No difference within and between groups could be demonstrated in SCL-90 score. CONCLUSIONS Rectal distensibility and volume thresholds for sensations decrease after stapled hemorrhoidopexy. Altered rectal distensibility was associated with rectal urgency and/or increased stool frequency.
Collapse
|
15
|
Kam MH, Lim JF, Ho KS, Ooi BS, Eu KW. Short-term results of DST EEA 33 stapler and neu@ anoscope for stapled haemorrhoidectomy: a prospective study of 1,118 patients from a single centre. Tech Coloproctol 2009; 13:273-7. [DOI: 10.1007/s10151-009-0532-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2009] [Accepted: 08/10/2009] [Indexed: 10/20/2022]
|
16
|
Naldini G, Martellucci J, Moraldi L, Romano N, Rossi M. Is simple mucosal resection really possible? Considerations about histological findings after stapled hemorrhoidopexy. Int J Colorectal Dis 2009; 24:537-41. [PMID: 19169693 DOI: 10.1007/s00384-009-0636-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2009] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The common removal of smooth muscle during stapled hemorrhoidectomy had raised concerns about its effects on postoperative anorectal function. The purpose of the study is to confirm the high frequency of the involvement of smooth muscle fibers in stapled hemorrhoidectomy and to determine its association with postoperative findings. METHODS This retrospective study evaluated 241 cases of stapled hemorrhoidopexy treated from 2003 to 2006. Data include the most common postoperative complications such as bleeding, anal pain, and recurrence. Histological doughnuts were examined, and the presence of muscle fibers was evaluated. RESULTS Early complications occurred in 27/241 patients (11.2%) including bleeding (14), anal pain (eight), incontinence (two), abscess (two), hematoma (one). Recurrence was observed in 11 cases (4.5%). Muscularis propria fibers were identified in 217 of 241 (90%) pathologic specimens. Five complications occurred in the group in which muscle fibers were not identified (4/24). The frequency of complications in the group with and without smooth muscle tissue in the resected specimens was 9.6% and 25%, respectively. CONCLUSIONS The presence of muscle fibers is not an occasional finding in the histological specimens, even if the presence of smooth muscle does not seems to influence the outcome of stapled hemorrhoidopexy. The idea of a simple mucosal resection needs to be revised.
Collapse
|
17
|
De Nardi P, Corsetti M, Passaretti S, Squillante S, Castellaneta AG, Staudacher C, Testoni PA. Evaluation of rectal sensory and motor function by means of the electronic barostat after stapled hemorrhoidopexy. Dis Colon Rectum 2008; 51:1255-60. [PMID: 18470557 DOI: 10.1007/s10350-008-9349-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2007] [Revised: 02/29/2008] [Accepted: 03/18/2008] [Indexed: 02/08/2023]
Abstract
PURPOSE Stapled hemorrhoidopexy is designed to replace the hemorrhoids into the anal canal by excising the redundant rectal mucosa above the anorectal ring, thus resulting in an intrarectal suture. Few studies have evaluated rectal function after this procedure. This prospective study was designed to use the electronic barostat to assess whether rectal motor and sensory functions change after stapled hemorrhoidopexy. METHODS Ten patients (4 women, mean age, 46 +/- 9 years) with third-degree and fourth-degree hemorrhoids who underwent stapled hemorrhoidopexy were studied. One week before and six months after surgery, they underwent three different rectal distensions (pressure-controlled stepwise, volume-controlled stepwise, and ramp) controlled by an electronic barostat. RESULTS Rectal distensibility was significantly lower after surgery during pressure stepwise (P = 0.01), during volume stepwise (P = 0.006), and during ramp distension (P = 0.001). Volume thresholds for desire to defecate, urgency, and discomfort were significantly lower after surgery during all three distensions (P < 0.05). Volume threshold for first perception also was significantly lower after surgery during volume ramp distension (P = 0.01). CONCLUSIONS Rectal distensibility and volume thresholds for sensations decrease after stapled hemorrhoidopexy. These impairments persist for at least six months after surgery.
Collapse
Affiliation(s)
- Paola De Nardi
- Surgical Department, San Raffaele Scientific Institute, Vita-Salute University San Raffaele, Milan, Italy.
| | | | | | | | | | | | | |
Collapse
|
18
|
Bozdag AD, Nazli O, Tansug T, Derici H, Kara C, Sozutek A. Videoanoscope-assisted stapled haemorrhoidopexy: analysis of 18 patients. Tech Coloproctol 2008; 12:123-6. [PMID: 18545879 DOI: 10.1007/s10151-008-0410-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2008] [Accepted: 04/10/2008] [Indexed: 11/29/2022]
Abstract
An optimal stapled haemorrhoidopexy requires the purse-string suture to be placed circumferentially at a constant distance from the dentate line and to pass through an appropriate thickness of rectal mucosa. An unsuitable purse-string suture may increase the risk of postoperative complications. We developed a new anoscope (the videoanoscope) to prevent the difficulties during application of the purse-string suture, and we used the videoanoscope in 18 stapled haemorrhoidopexy procedures. The videoanoscope is made up of three pieces. The front part is in the form of an open half-cylinder. The second piece is a sliding lid that covers the front piece. The rear part of the anoscope includes a hollow handle in which a scope can be inserted, and the whole procedure can be transmitted to a monitor via this scope. The opening on the anoscope can be adjusted by sliding the lid. A purse-string suture is placed on the rectal mucosa protruding through this adjustable opening. The anoscope is rotated to apply the subsequent suture bites and when the starting point is reached again the purse-string is completed. Then the stapled haemorrhoidopexy procedure is continued in the usual fashion. Videoanoscope-assisted stapled haemorrhoidopexy was easily performed in 18 patients (12 men, 6 women; mean age 48.9 years). The mean operative time was 32.8 minutes. The excised rectal mucosal rings were complete in all of the patients. Optimal purse-string depth was reflected in the presence of only mucosa and submucosa in all specimens, without incorporation of muscle cells. Postoperative complications were urinary retention in one patient and bleeding in five patients, one of whom requiring sutures for haemostasis. Further studies are required to assess the potential advantages of this technique.
Collapse
Affiliation(s)
- A D Bozdag
- 3rd Surgical Clinic, Izmir Ataturk Training and Research Hospital, Izmir, Turkey.
| | | | | | | | | | | |
Collapse
|
19
|
Wong JCH, Chung CC, Yau KK, Cheung HYS, Wong DCT, Chan OCY, Li MKW. Stapled technique for acute thrombosed hemorrhoids: a randomized, controlled trial with long-term results. Dis Colon Rectum 2008; 51:397-403. [PMID: 18097723 DOI: 10.1007/s10350-007-9085-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2007] [Revised: 05/31/2007] [Accepted: 06/30/2007] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was designed to compare stapled vs. conventional hemorrhoidectomy for patients with acute thrombosed hemorrhoids. METHODS Forty-one patients with acute thrombosed hemorrhoids were randomized into: 1) stapled hemorrhoidectomy (PPH group; n = 21), and 2) open hemorrhoidectomy (open group; n = 20). Emergency surgery was performed with perioperative data and complications were recorded. Patients were followed up by independent assessors to evaluate pain, recurrence, continence function, and satisfaction at regular intervals. RESULTS The median follow-up for the PPH group and open group were 59 and 56 weeks, respectively. There was no significant difference in terms of the hospital stay, complication rate, and continence function; however, the mean pain intensity in the first postoperative week was significantly less in the PPH group (4.1 vs. 5.7, P = 0.02). Patients in the PPH group recovered significantly faster in terms of the time to become analgesic-free (4 vs. 8.5 days, P < 0.01), time to become pain-free (9 vs. 20.5 days, P = 0.01), resumption of work (7 vs. 12.5 days, P = 0.01), and time for complete wound healing (2 vs. 4 weeks, P < 0.01). On long-term follow-up, significantly fewer patients in the PPH group complained of recurrent symptoms (0 vs. 5, P = 0.02). The overall symptom improvement and patients' satisfaction were significantly better in the PPH group (90 vs. 80 percent, P = 0.03 and +3 vs. +2, P < 0.01 respectively). CONCLUSIONS Stapled hemorrhoidectomy is safe and effective for acute thrombosed hemorrhoids. Similar to elective stapled procedure, emergency stapled excision has greater short-term benefits compared with conventional excision: diminished pain, faster recovery, and earlier return to work. Long-term results and satisfaction were excellent.
Collapse
Affiliation(s)
- J C H Wong
- Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong, SAR, China.
| | | | | | | | | | | | | |
Collapse
|
20
|
|
21
|
Ohana G, Myslovaty B, Ariche A, Dreznik Z, Koren R, Rath-Wolfson L. Mid-term results of stapled hemorrhoidopexy for third- and fourth-degree hemorrhoids--correlation with the histological features of the resected tissue. World J Surg 2007; 31:1336-42. [PMID: 17450437 DOI: 10.1007/s00268-007-9048-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Stapled hemorrhoidopexy is used to remove a circumferential strip of mucosa and submucosa about 4 cm above the dentate line, in order to restore the correct anatomical relationships of the anal canal structures. We evaluated the histological features of the resected tissue obtained after stapled hemorrhoidopexy with correlation to the short-term and mid-term results. METHODS This retrospective study evaluated 234 cases of stapled hemorrhoidopexy. Data concerning postoperative bleeding, anal pain, incontinence, stenosis, and recurrence of hemorrhoids were collected from hospital and outpatient clinic records. Histologic slides were examined for the type of epithelium, presence of muscle fibers, nerve endings, and degree of vascular ectasia. RESULTS Some 52% of the biopsies revealed on the surface a combination of glandular with squamous epithelium, meaning a stapling line at the level of the transitional zone/dentate line. Smooth muscle fibers were more frequent as the stapling line approached the level of the dentate line/transitional zone (p = 0.0028). Internal sphincter fibers were present in 36% of the cases, yet there were no cases of anal incontinence. Inclusion of merely squamous epithelium in the resected tissue correlated with severe postoperative pain persisting one week after surgery (p < 0.0001), whereas the concurrent presence of squamous and glandular epithelium correlated only with severe pain on the first postoperative day (p = 0.018). Nerve endings were more frequent in patients with anal pain one week after surgery (p = 0.02). The rate of recurrence of symptoms was 3%, which did not correlate with any of the histological parameters tested. CONCLUSIONS Though stapled hemorrhoidopexy is performed according to well-established technical guidelines, it is too difficult to be standardized.
Collapse
Affiliation(s)
- Gil Ohana
- Proctology Unit, Hasharon Hospital, 7 Keren Kayemet St., Petach Tikva, Israel.
| | | | | | | | | | | |
Collapse
|
22
|
Kaidar-Person O, Person B, Wexner SD. Hemorrhoidal Disease: A Comprehensive Review. J Am Coll Surg 2007; 204:102-17. [PMID: 17189119 DOI: 10.1016/j.jamcollsurg.2006.08.022] [Citation(s) in RCA: 141] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2006] [Revised: 08/24/2006] [Accepted: 08/25/2006] [Indexed: 12/11/2022]
Affiliation(s)
- Orit Kaidar-Person
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL 33331, USA
| | | | | |
Collapse
|
23
|
Feki A, Faltin DL, Lei T, Dubuisson JB, Jacob S, Irion O. Sphincter incontinence: is regenerative medicine the best alternative to restore urinary or anal sphincter function? Int J Biochem Cell Biol 2006; 39:678-84. [PMID: 17208507 DOI: 10.1016/j.biocel.2006.11.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2006] [Revised: 10/25/2006] [Accepted: 11/01/2006] [Indexed: 12/16/2022]
Abstract
Incontinence is a major public health concern in aging societies. It is caused by age-dependent spontaneous apoptosis of muscle cells in the urinary and fecal sphincters, and is aggravated in women due to birth trauma. Compared to other currently employed invasive surgical management techniques associated with morbidity and recurrence, replacement or regeneration of dysfunctional sphincter through stem cell therapy and tissue engineering techniques hold great promise. This review focuses on the pathophysiological analysis of urinary incontinence and the possible application of muscle-derived-stem cells, satellite cells, chondrocytes and adipose-derived-stem cells in restoring sphincter functions.
Collapse
Affiliation(s)
- A Feki
- Embryonic Stem Cell Research Laboratory, Switzerland.
| | | | | | | | | | | |
Collapse
|