Rectal distensibility and symptoms after stapled and Milligan-Morgan operation for hemorrhoids

The insoluble excretion of multi-matrix system mesalazine preparations in patients with ulcerative colitis

BACKGROUND

Multi-matrix mesalazine (MMX) is an important treatment for ulcerative colitis (UC); however, it is often excreted intact, which increases the risk of relapse. This study aimed to clarify the risk factors for insoluble MMX excretion.

METHODS

The subjects were 102 UC patients who were newly prescribed MMX alone to induce remission. Their stools were evaluated on the Bristol Stool Form Scale (BSFS), the presence/absence of insoluble MMX excretion was investigated in interviews, and defecation frequency at the start of treatment and disease type were retrospectively investigated by examining their medical records.

RESULTS

The insoluble excretion rate (IER) was 14.7%. It tended to be higher in the patients with left-sided colitis or extensive colitis, although the differences among the disease types were not significant (p = 0.053). The mean defecation frequency of the patients that reported insoluble MMX excretion was significantly higher than that of the patients that did not report it (6.27 ± 5.28 vs. 3.69 ± 3.17, p < 0.05). The IER tended to be higher among the patients with soft stools (4.5%, 21.9%, and 23.1% in those with BSFS scores of ≤ 4, 5, and ≥ 6, respectively). In ROC analysis of defecation frequency, ≥ 3.5 defecations was found to exhibit sensitivity and specificity of 66.7% and 65.5%, respectively, for predicting insoluble MMX excretion.

CONCLUSIONS

The likelihood of insoluble MMX excretion is influenced by defecation frequency and the extent of inflammation. It is important to keep the possibility of insoluble excretion in mind when prescribing MMX.

Partial Stapled Hemorrhoidopexy Versus Circumferential Stapled Hemorrhoidopexy for Grade III to IV Prolapsing Hemorrhoids: A Randomized, Noninferiority Trial

BACKGROUND

Long-term outcomes and efficacy of partial stapled hemorrhoidopexy are not known.

OBJECTIVE

The purpose of this study was to compare the long-term clinical efficacy and safety of partial stapled hemorrhoidopexy with circumferential stapled hemorrhoidopexy.

DESIGN

This was a parallel group, randomized, noninferiority clinical trial.

SETTINGS

The study was conducted at a single academic center.

PATIENTS

Patients with grade III/IV hemorrhoids between August 2011 and November 2013 were included.

INTERVENTIONS

Three hundred patients were randomly assigned to undergo either partial stapled hemorrhoidopexy (group 1, n = 150) or circumferential stapled hemorrhoidopexy (group 2, n = 150).

MAIN OUTCOME MEASURES

The primary outcome was the rate of recurrent prolapse at a median follow-up period of 5 years with a predefined noninferiority margin of 3.75%. Secondary outcomes included incidence and severity of postoperative pain, fecal urgency, anal continence, and the frequency of specific complications, including anorectal stenosis and rectovaginal fistula.

RESULTS

The visual analog scores in group 1 were less than those in group 2 (p < 0.001). Fewer patients in group 1 experienced postoperative urgency compared with those in group 2 (p = 0.001). Anal continence significantly worsened after both procedures, but the difference between preoperative and postoperative continence scores was higher for group 2 than for group 1. Postoperative rectal stenosis did not develop in patients in group 1, although it occurred in 8 patients (5%) in group 2 (p = 0.004). The 5-year cumulative recurrence rate between group 1 (9% (95% CI, 4%-13%)) and group 2 (12% (95% CI, 7%-17%)) did not differ significantly (p = 0.137), and the difference was within the noninferiority margin (absolute difference, -3.33% (95% CI, -10.00% to 3.55%)).

LIMITATIONS

The study was limited because it was a single-center trial.

CONCLUSIONS

Partial stapled hemorrhoidopexy is noninferior to circumferential stapled hemorrhoidopexy for patients with grade III to IV hemorrhoids at a median follow-up period of 5 years. However, partial stapled hemorrhoidopexy was associated with reduced postoperative pain and urgency, better postoperative anal continence, and minimal risk of rectal stenosis. See Video Abstract at http://links.lww.com/DCR/A790.Trial registration (chictr.org) identifier is chiCTR-trc-11001506.

Rectal tone and compliance affected in patients with fecal incontinence after fistulotomy

AIM

To investigate the anal sphincter and rectal factors that may be involved in fecal incontinence that develops following fistulotomy (FIAF).

METHODS

Eleven patients with FIAF were compared with 11 patients with idiopathic fecal incontinence and with 11 asymptomatic healthy subjects (HS). All of the study participants underwent anorectal manometry and a barostat study (rectal sensitivity, tone, compliance and capacity). The mean time since surgery was 28 ± 26 mo. The postoperative continence score was 14 ± 2.5 (95%CI: 12.4-15.5, St Mark's fecal incontinence grading system).

RESULTS

Compared with the HS, the FIAF patients showed increased rectal tone (42.63 ± 27.69 vs 103.5 ± 51.13, P = 0.002) and less rectal compliance (4.95 ± 3.43 vs 11.77 ± 6.9, P = 0.009). No significant differences were found between the FIAF patients and the HS with respect to the rectal capacity; thresholds for the non-noxious stimuli of first sensation, gas sensation and urge-to-defecate sensation or the noxious stimulus of pain; anal resting pressure or squeeze pressure; or the frequency or percentage of relaxation of the rectoanal inhibitory reflex. No significant differences were found between the FIAF patients and the patients with idiopathic fecal incontinence.

CONCLUSION

In patients with FIAF, normal motor anal sphincter function and rectal sensitivity are preserved, but rectal tone and compliance are impaired. The results suggest that FIAF is not due to alterations in rectal sensitivity and that the rectum is more involved than the anal sphincters in the genesis of FIAF.

Does the removal of retained staples really improve postoperative chronic sequelae after transanal stapled operations?

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.

The tissue-selecting technique: segmental stapled hemorrhoidopexy

We describe a technique for the management of prolapsing hemorrhoids, with the aim to minimize the risk of anal stricture and rectovaginal fistula and to reduce the impact of the stapling technique on rectal compliance. This modified procedure was successfully applied in China, and preliminary data showed promising outcomes (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A117).

Correlation of histopathology with anorectal manometry following stapled hemorrhoidopexy

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.

Agraffectomy after low rectal stapling procedures for hemorrhoids and rectocele

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.