Randomized controlled trial to compare the early and mid-term results of stapled versus open hemorrhoidectomy

Early and midterm results of radiofrequency ablation (Rafaelo® procedure) for third-degree haemorrhoids: a prospective, two-centre study

Background

The aim of this study was to evaluate the safety and efficacy of radiofrequency ablation (RFA) for treating third degree haemorrhoids, with a follow-up over 2 years.

Methods

We conducted a prospective, two-centre study to assess RFA of third-degree haemorrhoids in an outpatient setting. Treatment was performed under local anaesthesia, optionally in combination with sedation. The primary endpoint was analysis of a proctological symptom score ([PSS] bleeding, itching, pain, soiling) and proctological examination to detect recurrence at 1, 6, 12 and 24 months after surgery. The secondary endpoints were postoperative complications, incidence of postoperative pain, including administration of analgesics and time to return to daily routine.

Results

Ninety-eight patients were included in the study. The mean age of the patients was 49.1 ± 10.9 (mean ± SD). 83 patients (84.7%) were male and 15 patients (15.3%) were female. The follow-up involved 100% (1 month), 95% (6 months), 86% (12 months) and 74% after 24 months. The individual symptom scores and overall PSS score decreased significantly in comparison to the initial score at each time point assessed. Prolapsed haemorrhoids decreased in comparison to the initial situation (100%) to 7.2% (1 month), 3.5% (6 months), 13.1% (12 months) and 13.7% (after 24 months). Thirteen patients (12.7%) required repeat haemorrhoid therapy during the 2-year follow-up period. The mean maximum pain score after the procedure was 2.5 ± 2.7 (determined with the visual analogue scale), while 33 (33.7%) patients reported having no pain. 59 (60.2%) patients did not take analgesics after the procedure. Eleven patients (11.2%) experienced minor complications (bleeding, fever, cramps, diarrhoea, anal venous thrombosis) but did not require additional treatment. Eight cases (8.2%) of major complications (infection, bleeding, severe pain) required treatment with antibiotics, a second intervention, analgesics or hospitalization.

Conclusions

RFA is safe and effective for treatment of third-degree haemorrhoids. The main advantages of this new method are its use on an outpatient basis under local anaesthesia, a very low level of postoperative pain and significant control of haemorrhoid symptoms over 2 years.

Surgical Clinical Trials in India: Underutilized Opportunities

Clinical trials in Surgery are central to research; however, very few surgical clinical trials are conducted in India. Such paucity of surgical trials is a cause for concern, and prompted us to explore the recent landscape of surgical trials in India. We reviewed all clinical trials from general surgery or subspecialties of general surgery registered with the Clinical Trials Registry of India website between 2018 to 15 th May 2021. Specific details such as the surgical subspecialty, study design, multicentric or single institution and funding were obtained. We found a total of 16,710 trials, out of these 4119 (24.6%) were related to all surgical fields. Only 136 (0.8%) trials were found from general surgery and its subspecialties. Most trials were registered from Central Government Institutions (48%), followed by State Government Medical Colleges (11%). Most number of trials was registered from GI surgery (32%). Most (90.5%) trials were single centre based. Common barriers to research are well known; if the State Government Medical Colleges can mentor a culture of research from an early stage of surgical training it can improve research productivity. Multicentre trials, involving smaller hospitals from tier 2 and tier 3 cities, are a potential solution to one of the major obstacles of surgical trials i.e. small number of patients; especially in this pandemic induced draught of elective surgical operations. A positive change in attitude of surgeons and provision of necessary funding can encourage more surgical clinical trials in India.

A systematic review of the literature assessing the outcomes of stapled haemorrhoidopexy versus open haemorrhoidectomy

Background

Symptomatic haemorrhoids affect a large number of patients throughout the world. The aim of this systematic review was to compare the surgical outcomes of stapled haemorrhoidopexy (SH) versus open haemorrhoidectomy (OH) over a 20-year period.

Methods

Randomized controlled trials published between January 1998 and January 2019 were extracted from Pubmed using defined search criteria. Study characteristics and outcomes in the form of short-term and long-term complications of the two techniques were analyzed. Any changes in trend of outcomes over time were assessed by comparing article groups 1998–2008 and 2009–2019.

Results

Twenty-nine and 9 relevant articles were extracted for the 1998–2008 (period 1) and 2009–2019 (period 2) cohorts, respectively. Over the two time periods, SH was found to be a safe procedure, associated with statistically reduced operative time (in 13/21 studies during period 1 and in 3/8 studies during period 2), statistically less intraoperative bleeding (3/7 studies in period 1 and 1/1 study in period 2) and consistently less early postoperative pain on the visual analogue scale (12/15 studies in period 1 and 4/5 studies in period 2) resulting in shorter hospital stay (12/20 studies in period 1 and 2/2 studies in period 2) at the expense of a higher cost. In the longer term, although chronic pain in SH and OH patents is comparable, patient satisfaction with SH may decline with time and at 2-year follow-up OH appeared to be associated with greater patient satisfaction.

Conclusions

SH appears to be safe with potential advantages, at least in the short term, but the evidence is lacking at the moment to suggest its routine use in clinical practice.

Network meta-analysis of randomized controlled trials comparing the procedure for prolapse and hemorrhoids, Milligan-Morgan hemorrhoidectomy and tissue-selecting therapy stapler in the treatment of grade III and IV internal hemorrhoids(Meta-analysis)

BACKGROUND

Hemorrhoids are one of the most common conditions in the world, and grade III and IV internal hemorrhoids are mainly treated with surgery. However, there are many different surgical methods, and many postoperative complications occur. Therefore, we aimed to update and expand our previous work to compare the safety and efficacy of the procedure for prolapse and hemorrhoids (PPH), Milligan-Morgan hemorrhoidectomy (MMH) and tissue-selecting therapy stapler (TST) in the treatment of grade III and IV internal hemorrhoids.

METHODS

We performed a network meta-analysis. We searched the Cochrane library, Embase, PubMed, Medline, Web of Science, CNKI, Wangfang, and VIP databases up to May 20, 2019. All randomized controlled trials (RCTs) comparing PPH, MMH and TST in the treatment of grade III and IV internal hemorrhoids were included. We performed a Bayesian network meta-analysis to integrate the adverse events of all treatments. This work is reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and Assessing the Methodological Quality of Systematic Reviews (AMSTAR) guidelines. This study was registered with PROSPERO, number CRD42019137270.

RESULT

Twenty-two RCTs that recruited 3511 patients were identified. Among these patients, 1379 patients underwent PPH, 805 patients underwent TST, and 1327 patients underwent MMH. In terms of adverse events, TST presented the lowest urinary retention rates and fecal incontinence rates. TST exhibited fewer incidences of anal stenosis than PPH and MMH. Importantly, PPH showed the weakest effects on reducing recurrence rates in hemorrhoid patients.

CONCLUSIONS

The current study indicated that TST showed optimal potential superior clinical effects for grade III and IV hemorrhoids compared to PPH and MMH. However, high-quality large sample RCTs are still expected.

LONG TERM RESULTS AFTER STAPLED HEMORRHOIDOPEXY ALONE AND COMPLEMENTED BY EXCISIONAL HEMORRHOIDECTOMY: A RETROSPECTIVE COHORT STUDY

Background:

Stapled hemorrhoidopexy is associated with less postoperative pain and faster recovery. However, it may be associated with a greater risk of symptomatic recurrence. We hypothesized that undertaking a limited surgical excision of hemorrhoid disease after stapling may be a valid approach for selected patients.

Aim:

To compare long-term results after stapled hemorrhoidopexy with and without complementation with closed excisional technique.

Method:

In a retrospective uni-institutional cohort study, sixty-five (29 men) patients underwent stapled hemorrhoidopexy and 21 (13 men) underwent stapled hemorrhoidopexy with excision. The same surgeons operated on all cases. Patients underwent stapled hemorrhoidectomy associated with excisional surgery if symptoms attributable to external hemorrhoid piles were observed preoperatively, or if residual prolapse or bulky external disease was observed after the firing of the stapler. A closed excisional diathermy hemorrhoidectomy without vascular ligation was utilized in all complemented cases. All clinical variables were obtained from a questionnaire evaluation obtained through e-mail, telephone interview, or office follow-up.

Results:

The median duration of postoperative follow-up was 48.5 (6-40) months. Patients with grades 3 and 4 hemorrhoid disease were operated on more frequently using stapled hemorrhoidopexy complemented with excisional technique (95.2% vs. 55.4%, p=0.001). Regarding respectively stapled hemorrhoidopexy and stapled hemorrhoidopexy complemented with excision, there was no difference between the techniques in relation to symptom recurrence (43% and 33%, p=0.45) and median interval between surgery and symptom recurrence (30 (8-84) and 38.8 (8-65) months, p=0.80). Eight (12.3%) patients were re-operated after stapled hemorrhoidopexy and 2 (9.6%), after hemorrhoidopexy with excision (p=0.78). Patient distribution in both groups according to the degree of postoperative satisfaction was similar (p=0.97).

Conclusion:

Stapled hemorrhoidopexy combined with an excisional technique was effective for more advanced hemorrhoid disease. The combination may have prevented symptomatic recurrence associated to stapled hemorrhoidopexy alone.

Doppler-Guided Transanal Hemorrhoidal Dearterialization (DG-THD) Versus Stapled Hemorrhoidopexy (SH) in the Treatment of Third-Degree Hemorrhoids: Clinical Results at Short and Long-Term Follow-Up

INTRODUCTION

The stapled hemorrhoidopexy (SH) and the Doppler-guided transanal hemorrhoidal dearterialization (DG-THD) are minimally invasive procedures for the surgical treatment of hemorrhoids. This study aims to verify the efficacy of the DG-THD versus the SH in the treatment of third-degree hemorrhoids.

METHOD

One hundred consecutive patients were causally allocated to either procedure, obtaining two groups of 50 pts. A clinical examination was performed at 3, 7, 15, and 30 days after the operation. Quality of life, anal symptoms, recurrence of hemorrhoids, and reoperation were assessed by means of a questionnaire and of a clinical examination at long-term follow-up (7.0 year average).

RESULTS

At short-term follow-up, the median postoperative pain score was significantly lower in DG-THD group compared to SH group, (V.A.S 2 vs 6; t = 2.65, p < 0.01). The morbidity rate and the return to normal life and work were similar after the two procedures. At long-term follow-up, the incidence of piles was not statistically different between the two groups (DG-THD 10.0 %; SH 14.0 %). No differences were reported by patients in terms of satisfaction for surgery.

CONCLUSION

SH and DG-THD procedures do not show significantly different results with regard to the patients outcome. However, considering the lower p. o. pain, the DG-THD might be proposed as the first line treatment in third-degree hemorrhoids.

Documented complications of staple hemorrhoidopexy: a systematic review

A systematic review addressing reported complications of stapled hemorrhoidopexy was conducted. Articles were identified via searching OVID and MEDLINE between July 2011 and October 2013. Limitations were placed on the search criteria with articles published from 1998 to 2013 being included in this review. No language restrictions were placed on the search, however foreign language articles were not translated. Two reviewers independently screened the abstracts for relevance and their suitability for inclusion. Data extraction was conducted by both reviewers and entered and analyzed in Microsoft Excel. The search identified 784 articles and 78 of these were suitable for inclusion in the review. A total of 14,232 patients underwent a stapled hemorrhoidopexy in this review. Overall complication rates of stapled hemorrhoidopexy ranged from 3.3%-81% with 5 mortalities documented. Early and late complications were defined individually with overall data suggesting that early complications ranged from 2.3%-58.9% and late complications ranged from 2.5%-80%. Complications unique to the procedure were identified and rates recorded. Both early and late complications unique to stapled hemorrhoidopexy were identified and assessed.

Anal cushion lifting method is a novel radical management strategy for hemorrhoids that does not involve excision or cause postoperative anal complications

AIM: To describe the anal cushion lifting (ACL) method with preliminary clinical results.

METHODS: Between January to September 2007, 127 patients who received ACL method for hemorrhoid was investigated with informed consent. In this study, three surgeons who specialized in anorectal surgery performed the procedures. Patients with grade two or more severe hemorrhoids according to Goligher’s classification were considered to be indicated for surgery. The patients were given the choice to undergo either the ACL method or the ligation and excision method. ACL method is an original technique for managing hemorrhoids without excision. After dissecting the anal cushion from the internal sphincter muscle, the anal cushion was lifted to oral side and ligated at the proper position. Clinical characteristics and outcomes of patients were recorded including complications after surgery.

RESULTS: A total of 127 patients were enrolled. Their median age was 42 (19-84) years, and 74.8% were female. In addition, more than 99% of the patients had grade 3 or worse hemorrhoids. The median follow-up period was 26 (0-88) mo, and the median operative time was 15 (4-30) min. After surgery, analgesics were used for a median period of three days (0-21). Pain control was achieved using extra-oral analgesic drugs, although some patients required intravenous injections of analgesic drugs. The median duration of the patients’ postoperative hospital stay was 7 (2-13) d. A total of 10 complications (7.9%) occurred. Bleeding was observed in one patient and was successfully controlled with manual compression. Urinary retention occurred in 6 patients, but it disappeared spontaneously in all cases. Recurrent hemorrhoids developed in 3 patients after 36, 47, and 61 mo, respectively. No anal stenosis or persistent anal pain occurred.

CONCLUSION: We consider that the ACL method might be better than all other current methods for managing hemorrhoids.

Systematic review and network meta-analysis comparing clinical outcomes and effectiveness of surgical treatments for haemorrhoids

BACKGROUND

The aim was to compare the clinical outcomes and effectiveness of surgical treatments for haemorrhoids.

METHODS

Randomized clinical trials were identified by means of a systematic review. A Bayesian network meta-analysis was performed using the Markov chain Monte Carlo method in WinBUGS.

RESULTS

Ninety-eight trials were included with 7827 participants and 11 surgical treatments for grade III and IV haemorrhoids. Open, closed and radiofrequency haemorrhoidectomies resulted in significantly more postoperative complications than transanal haemorrhoidal dearterialization (THD), LigaSure™ and Harmonic® haemorrhoidectomies. THD had significantly less postoperative bleeding than open and stapled procedures, and resulted in significantly fewer emergency reoperations than open, closed, stapled and LigaSure™ haemorrhoidectomies. Open and closed haemorrhoidectomies resulted in more pain on postoperative day 1 than stapled, THD, LigaSure™ and Harmonic® procedures. After stapled, LigaSure™ and Harmonic® haemorrhoidectomies patients resumed normal daily activities earlier than after open and closed procedures. THD provided the earliest time to first bowel movement. The stapled and THD groups had significantly higher haemorrhoid recurrence rates than the open, closed and LigaSure™ groups. Recurrence of haemorrhoidal symptoms was more common after stapled haemorrhoidectomy than after open and LigaSure™ operations. No significant difference was identified between treatments for anal stenosis, incontinence and perianal skin tags.

CONCLUSION

Open and closed haemorrhoidectomies resulted in more postoperative complications and slower recovery, but fewer haemorrhoid recurrences. THD and stapled haemorrhoidectomies were associated with decreased postoperative pain and faster recovery, but higher recurrence rates. The advantages and disadvantages of each surgical treatment should be discussed with the patient before surgery to allow an informed decision to be made.

Emborrhoid: a new concept for the treatment of hemorrhoids with arterial embolization: the first 14 cases

PURPOSE

The 'emborrhoid' technique consists of the embolization of the hemorrhoidal arteries. The endovascular arterial occlusion is performed using coils placed in the terminal branches of the superior rectal arteries. The emborrhoid technique has been modeled after elective transanal Doppler-guided hemorrhoidal artery ligation which has been shown to be effective in hemorrhoidal disease. We report the first 14 cases of our experience with emborrhoid technique.

MATERIALS AND METHODS

Fourteen patients with disabling chronic rectal bleeding were treated using the emborrhoid technique (3 women, 11 men). The stage of the hemorrhoidal disease was II (10 patients), III (3), and IV (1). This treatment was decided by a multidisciplinary team (proctologist, visceral surgeon, and radiologist). Seven patients underwent previous proctological surgery. Ten patients had coagulation disorders (anticoagulants or cirrhosis). Superior rectal arteries were embolized with pushable microcoils (0.018).

RESULTS

Technical success of the embolization procedure was 100 %. Clinical success at 1 month was 72 % (10/14). Of the 4 patients who experienced rebleeding, two underwent additional embolization of the posterior rectal arteries with success. No pain or ischemic complications were observed in 13 patients. One patient experienced a temporary painful and edematous, perianal reaction.

CONCLUSION

Our case studies suggest that coil embolization of the superior rectal arteries is technically feasible, safe and well tolerated. Additional studies are needed to evaluate the efficacy of this new 'emborrhoid' technique in the management of hemorrhoidal disease.

Pneumoretroperitoneum after procedure for prolapsed hemorrhoid

Procedure for prolapsed hemorrhoid (PPH) is well recognized alternative to the traditional hemorrhoidectomy, and is associated with reduced pain and earlier return to normal activity. Over the past decade, there have been reports of severe life-threatening complications after a PPH, although the incidence is very low. Rectal perforation due to staple-line dehiscence is one of the serious complications that can cause severe pelvic sepsis or a pneumoretroperitoneum. Here, the first Korean case of a pneumoretroperitoneum due to staple-line dehiscence is described.

Stapled hemorrhoidectomy; results of a prospective clinical trial in saudi arabia

OBJECTIVES

This study was designed to evaluate the effectiveness of stapled hemorrhoidectomy (SH) in terms of cure of the symptoms and post-operative pain control.

MATERIAL AND METHODS

In this prospective clinical study, SH (Ethicon Endo-surgery, Cincinnati, OH) was performed for all patients with grade III and grade IV hemorrhoids, presenting to the surgical clinics of Ohud and Meeqat Hospitals Almadinah Almunawwarah Saudi Arabia. The results of SH were evaluated by a questionnaire focusing on the relief of symptoms, severity of post operative pain, and complications of SH.

RESULTS

Thirty patients (21 males and 9 females); with a mean age of 39.6 years were recruited in this study. Twenty six (86%) patients had grade III and 4 (14%) presented with grade IV hemorrhoids. Perianal prolapse was the most frequent presentation reported in 23 (76%). Mean operating time was 21.7 minutes (range; 17-36 minutes) whereas mean hospital stay was 1.9 days. Post-operative pain was tolerable (non-persistent) in 28 (93%) cases whereas 2 (7%) experienced mild pain requiring additional analgesia. Urinary retention was the most common complication found in 5 (16%) patients. All patients were cured of the hemorrhoids Conclusion: SH is a safe, rapid, and convenient surgical remedy for grade III and grade IV hemorrhoids with low rate of complications, minimal postoepative pain, and early discharge from the hospital.

Stapled and conventional Milligan-Morgan haemorrhoidectomy: different solutions for different targets

PURPOSE

Haemorrhoidal disease is one of the most common anorectal disorders. The aim of this study is to compare the results, over the last 10 years, of stapled haemorrhoidopexy (SH) with those of standard Milligan-Morgan haemorrhoidectomy (M&M). Furthermore, we discuss the proper indications for each technique in terms of the lowest rate of complications and long-term results.

METHODS

Three hundred forty-three patients with different degrees of symptomatic haemorrhoids underwent SH or M&M from January 2005 to December 2007. Patients were divided into two groups, age and sex matched. The administration of painkillers drugs, antibiotics and laxatives, complication symptoms and hospital stay in all the patients were recorded after surgical treatment.

RESULTS

The mean operative time was shorter in the stapled group compared to that in the open group (31 min versus 40 min). Postoperative pain, hospital stay and return to full activity were shorter in the stapled group. There was a significant difference in the wound healing time between the two groups. We noticed a higher rate of recurrence in patients treated with stapled haemorrhoidectomy for fourth-degree haemorrhoids.

CONCLUSIONS

According to our experience, the Longo technique is indicated for the treatment of haemorrhoids of second- and third degree. In the latter grades of prolapse, the Milligan-Morgan haemorrhoidectomy can also be applied with good outcomes. We believe that, in case of irreducible prolapse, the M&M is to be preferred. However, operative management varies according to surgeon's interest and is tailored to meet the individual patient's need.

Endoscopic band ligation of internal haemorrhoids versus stapled haemorrhoidopexy in patients with portal hypertension

BACKGROUND AND STUDY AIM

Portal hypertension is common in Egypt as a sequela to the high prevalence of hepatitis C virus and bilharziasis. In portal hypertension internal haemorrhoids are frequently found. The aim of this work was to compare the outcome of endoscopic band ligation (EBL) of symptomatic internal haemorrhoids with that of stapled haemorrhoidopexy (SH) in Egyptian patients with portal hypertension.

PATIENTS AND METHODS

In this study, 26 portal hypertensive patients (with oesophageal and/or fundal varices) with a grade 2-4 internal haemorrhoids who had no coagulation disorders were randomised to treatment by EBL (13 patients) or SH (13 patients) after doing colonoscopy. Symptom scores of bleeding and prolapse were assessed before and after the intervention. Complications were recorded. Patients were followed up for 12months.

RESULTS

Goligher's grades of internal haemorrhoids improved significantly (p=0.018) 12weeks after SH (from 2.9±0.8 to 0.4±0.5; p=0.001) and after EBL (from 2.8±0.8 to 1.1±0.8; p=0.001). Symptom (bleeding and prolapse) scores significantly improved 4weeks after both EBL (from 1.6±0.8 to 0.6±0.8; p<0.001 and from 1.6±0.9 to 0.5±0.5; p=0.002, respectively) and SH (from 1.8±0.8 to 0.2±0.4; p=0.002 and from 1.5±0.9 to 0.2±0.4; p=0.001, respectively). The differences after 4weeks between EBL and SH were not significant (p=0.168 and p=0.225). Pain requiring analgesics occurred in five patients (38.5%) after EBL, compared with six (46.2%) after SH (p=0.691). Minimal bleeding occurred in two patients (15.4%) after EBL but not with SH; urinary retention was observed in one patient after EBL compared with two after SH; and anal fissures were observed in one patient after EBL. During 1-year follow-up, increased frequency of stool occurred in one patient after EBL. Recurrence of symptoms was observed in three patients after EBL and in one after SH.

CONCLUSION

For portal hypertensive patients with internal haemorrhoids and without coagulation disorders SH seems to be superior to EBL. However further studies are needed to evaluate EBL in different grades of cirrhosis.

Long-term clinical results of double-pursestring stapled hemorrhoidopexy in a selected group of patients for the treatment of chronic hemorrhoids

BACKGROUND AND OBJECTIVE

The aim of this prospective controlled trial was to evaluate the long-term clinical and manometric results of stapled hemorrhoidopexy performed by expert surgeons in a selected group of patients for the treatment of chronic hemorrhoids.

SETTINGS

This study took place in the outpatient clinic and at the Day Surgery Unit attached to the University Hospital of Elche.

PATIENTS

From March 2003 to May 2005, 200 consecutive patients with third-degree hemorrhoids and treated with double-pursestring stapled hemorrhoidopexy with a PPH33-03 stapler were included in the study.

MAIN OUTCOME MEASURES

Demographic, manometric, and clinical features were analyzed, as well as the variables related to surgery, postoperative course, and follow-up. Manometry was repeated at the 6-month, 1-year, and 5-year follow-up.

RESULTS

Median follow-up was 110 months. Four patients (2%) reported daily rectal bleeding. One patient with active rectal bleeding was taken for reoperation within the first 12 postoperative hours. Seventy percent of patients reported pain ≤ 2 on the first postoperative day, 85% on the fourth postoperative day, and 95% on the seventh postoperative day. Pain was measured with a linear analog scale from 0 to 10 (0 = no pain; 10 = unbearable pain). Seventeen patients (8.5%) reported tenesmus during the first week. Eight patients (4%) reported persistent pain: in 5 patients, the pain resolved within the next 6 months; 2 patients presented with anal fissure; and 1 patient required the removal of the staples. Two patients (1%) reported residual soiling at the 5-year revision. Fourteen patients (7%) experienced recurrence with symptomatic prolapse. Six (3%) underwent further surgery: stapled hemorrhoidopexy was indicated again in 2 patients, and 4 patients underwent a Milligan-Morgan open hemorrhoidectomy, because they did not have a uniform prolapse. Six patients required treatment with rubber band ligation. There were no statistically significant differences between preoperative and postoperative manometric values.

CONCLUSIONS

The new PPH33-03 stapler, the learning process of the modified surgical procedure, and the correct selection of patients will overcome the main objections to stapled hemorrhoidopexy.

Evidence-based management of pain after haemorrhoidectomy surgery

BACKGROUND

Haemorrhoidectomy is associated with intense postoperative pain, but optimal evidence-based pain therapy has not been described. The aim of this systematic review was to evaluate the available literature on the management of pain after haemorrhoidal surgery.

METHODS

Randomized studies published in the English language from 1966 to June 2006, assessing analgesic and anaesthetic interventions in adult haemorrhoidal surgery, and reporting pain scores, were retrieved from the Embase and MEDLINE databases.

RESULTS

Of the 207 randomized studies identified, 106 met the inclusion criteria, with mixed methodological quality. Of these, 41 studies evaluating surgical and alternative interventions were excluded. Quantitative analyses were not performed, as there were limited numbers of trials with a sufficiently homogeneous design.

CONCLUSION

Local anaesthetic infiltration, either as a sole technique or as an adjunct to general or regional anaesthesia, and combinations of analgesics (non-steroidal anti-inflammatory drugs, paracetamol and opiates) are recommended. If appropriate, a stapled operation may be preferable.

LigaSure hemorrhoidectomy versus stapled hemorrhoidopexy: a prospective, randomized clinical trial

PURPOSE

This study was designed to compare the outcome of LigaSure hemorrhoidectomy and stapled hemorrhoidopexy for prolapsed hemorrhoids.

METHODS

Consecutive patients with grade III or IV hemorrhoids were randomly assigned to undergo either LigaSure hemorrhoidectomy or stapled hemorrhoidopexy. Data on patient demographic and clinical characteristics, operative details, postoperative pain score on a visual analog scale, number of parenteral analgesic injections, duration of hospital stay, and time to return to work were all prospectively collected. Postoperative complications and recurrence of prolapse were also recorded. Patients were regularly followed for a total period of 12 months.

RESULTS

A total of 68 patients completed the study (34 per group). Patient demographic and clinical characteristics were similar in the 2 groups. No significant differences between LigaSure hemorrhoidectomy and stapled hemorrhoidopexy were observed in mean operating time, postoperative pain score, number of parenteral analgesic injections, duration of hospital stay, or time to return to work. The groups were also similar regarding postoperative complications, except that at 4 weeks postoperatively, residual prolapse was observed in 8 patients (23.5%) in the stapled hemorrhoidopexy group vs. 2 patients (5.9%) in the LigaSure group (P = .040). Rate of recurrence of prolapse at 1 year was higher with stapled hemorrhoidopexy (4 patients, 11.8%) than with the LigaSure procedure (1 patient, 2.9%), but the difference was not significant (P = .163).

CONCLUSIONS

LigaSure hemorrhoidectomy and stapled hemorrhoidopexy yield comparable good results, with a short operative time and minimal side effects in the treatment of grade III and IV hemorrhoids, but with a lower rate of residual prolapse for the LigaSure procedure. Both procedures offer low levels of postoperative pain and therefore are excellent therapeutic options for prolapsed grade III and IV hemorrhoids. A larger controlled study is needed to reach solid conclusions regarding risk of postoperative recurrence of hemorrhoidal prolapse.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A novel technique for the treatment of post operative retro-rectal haematoma: two case reports

Rectal bleeding following any form of rectal surgery is a well recognised complication 1, 2, 3 & 4. However retro-rectal bleeding and tracking which then presents as rectal bleeding has not been reported in the literature. We describe a novel way of dealing with this technically difficult post-operative complication.

We present two cases of significant rectal bleeding (one following STARR procedure and other after Delormes procedure). Both patients had to be taken back to theatre due to continuing, significant bleeding. Examination under anaesthesia on both occasions revealed a posterior boggy swelling, with an opening which admitted a finger. In both cases clots were evacuated and a corrugated drain was inserted in to the retro rectal space.

The authors believe that following any form of rectal surgery, retro-rectal bleeding with tracking can present as rectal bleeding. Treatment in the form of EUA and insertion of corrugated helped to resolve the problem.

We present both cases and literature review of the complications of stapled haemorrhoidopexy.

Ligasure versus diathermy hemorrhoidectomy under spinal anesthesia or pudendal block with ropivacaine: a randomized prospective clinical study with 1-year follow-up

PURPOSE

We evaluate the safety and efficacy of a spinal anesthesia with lidocaine versus a local anesthesia of pudendal block with ropivacaine combined with intravenous sedation in the hemorrhoidectomy procedure and also we compared the short- and long-term efficacy of conventional diathermy versus Ligasure diathermy hemorrhoidectomy.

METHODS

Seventy-four patients of grade III or IV hemorrhoids were randomized to conventional diathermy hemorrhoidectomy under spinal (n = 19) or local anesthesia (n = 18) and Ligasure diathermy hemorrhoidectomy under spinal (n = 17) or local anesthesia (n = 20). Time of follow-up was 12 months.

RESULTS

Patients operated under local anesthesia had less pain (p < 0.01), less analgesic requirements (p < 0.001), shorter hospital stay (p < 0.01), and less postoperative complications (p < 0.05). A shorter operating time (p < 0.001) and less complications at 4 months postoperatively (p < 0.05) was observed in the Ligasure group, but differences at 12 months were not found.

CONCLUSIONS

Hemorrhoidectomy under local anesthesia with pudendal block with ropivacaine and sedation reduced postoperative pain, analgesic requirements, and postoperative complications, and can be performed as day-case procedure. Ligasure diathermy hemorrhoidectomy reduced operating time and was equally effective than conventional diathermy in long-term symptom control.

Transanal open hemorrhoidopexy

INTRODUCTION

Despite all developments in the recent years, the choice of an adequate treatment for hemorrhoids remains a problem. The hemorrhoidopexy as described by Longo and the Doppler-guided hemorrhoidal artery ligation follow a concept different from the excision and destruction techniques from earlier years. In both techniques, the hemorrhoidal tissue is preserved, as it may be important for anal sensation and continence. The high costs of the circular stapler gun and the Doppler methods can probably be overcome by the proposed technique, a transanal open hemorrhoidopexy, while simultaneously preserving hemorrhoidal tissues.

METHODS

Between November 2006 and May 2007, 38 patients with third-degree hemorrhoids were treated with open transanal hemorrhoidopexy. All patients were positioned in the lithotomy position and operated under general anesthesia; the anal mucosa was stitched to the rectal wall with four Z-stitches after removal of a small rectal mucosa flap about 4 cm from the dentate line. The four stitches were circumferentially positioned at equal distances. Postoperatively, the patients followed a fiber-rich diet for one week.

RESULTS

Most patients (n = 32, 84 percent) were without any complaint upon follow-up at one week. Six patients (16 percent) experienced pain and were treated with oral analgesics. One patient (3 percent) experienced minor bleeding that stopped spontaneously. After one month follow-up, 34 patients (89 percent) had no symptom complaints. Two patients (5 percent) experienced segmental prolapse and two patients (5 percent) had remaining pruritus. No patient needed another intervention.

CONCLUSION

The proposed operation, transanal open hemorrhoidopexy, appears to be an effective technique. The procedure can be performed under direct vision and is very cost effective compared to the other hemorrhoidal tissue-sparing procedures.

Stapled haemorrhoidopexy compared to Milligan-Morgan and Ferguson haemorrhoidectomy: a systematic review

PURPOSE

The aim of this study was to perform a systematic review and meta-analysis of the short- and long-term outcomes of stapled haemorrhoidopexy.

METHODS

A literature search identified randomised controlled trials comparing stapled haemorrhoidopexy with Milligan-Morgan/Ferguson haemorrhoidectomy. Data were extracted independently for each study and differences analysed with fixed and random effects models.

RESULTS

Thirty-four randomised trials and two systematic reviews were identified, and 29 trials included. Stapled haemorrhoidopexy was statistically superior for hospital stay (p < 0.001) and numerically superior for post-operative pain (peri-operative and mid-term), operation time and bleeding (post-operative and long-term). Recurrent prolapse and re-intervention for recurrence were more frequent following stapled haemorrhoidopexy. No difference was observed in the rates of complications.

CONCLUSIONS

Stapled haemorrhoidopexy reduces the length of hospital stay and may have an advantage in terms of decreased operating time, reduced post-operative pain and less bleeding but is associated with an increased rate of recurrent prolapse.

Stapled haemorrhoidopexy for the treatment of haemorrhoids: a systematic review

OBJECTIVE

This systematic review aimed to evaluate the short- and long-term safety, efficacy and costs of stapled haemorrhoidopexy (SH) compared with conventional haemorrhoidectomy.

METHOD

We searched 26 electronic databases and websites for studies in any language up to July 2006. Inclusion criteria were predefined, and each stage of the review process was conducted in duplicate.

RESULTS

Twenty-seven randomized controlled trials were included (n = 2279). All had some methodological flaws. Postoperatively, 19 trials (95%) reported less pain, 17 (89%) reported a shorter operating time, 14 (88%) a shorter hospital stay, and 14 (93%) a shorter convalescence time following SH. However, prolapse was significantly more common after SH (OR 3.38; 95% CI: 1.00, 11.47). In the longer term, prolapse was significantly more common after SH (OR 4.34; 95% CI: 1.67, 11.28) as was reintervention for prolapse (OR 6.78; 95% CI: 2.00, 23.00). There were no differences in the rate or type of complications. Conventional haemorrhoidectomy and SH had similar costs during the initial admission.

CONCLUSION

Compared with conventional haemorrhoidectomy, SH resulted in less postoperative pain, shorter operating time, a shorter hospital stay, and a shorter convalescence, but a higher rate of prolapse and reintervention for prolapse.

The evaluation of CEEA 34 for stapled hemorrhoidectomy: results of a prospective clinical trial and patient satisfaction

INTRODUCTION

Stapled hemorrhoidectomy (SH) has routinely been performed using Procedure for Prolapse and Hemorrhoids Proximate Hemorrhoidal Circular Staplers (Ethicon Endo-surgery, Cincinnati, OH). Premium Plus CEEA 34 (Tyco Healthcare, New Haven, CT) has been recently introduced for SH. This study aims to review the effectiveness of CEEA 34 for SH.

METHODS

From April to June 2007, the SH procedure was performed or supervised by 5 experienced consultant surgeons. A quality of life telephone survey was performed within 4 to 6 weeks postoperatively.

RESULTS

Two hundred thirteen patients (52% men and 48% women) with a median age of 46 years (range 26-78 years) underwent SH during the trial period. Median duration of surgery was 10 minutes (range 5-35 minutes). Ninety-seven percent underwent SH for third- and fourth-degree piles. Ten patients (4.7%) had bleeding postoperatively in the first week that ceased with adrenaline injection or pack, and 2 required transfusions. Eighty-three percent participated in the quality of life survey, and 92% of these patients expressed satisfaction with the outcome of the procedure.

CONCLUSION

CEEA 34 for SH is safe and effective with few postoperative complications and high patient satisfaction.

Procedure for Prolapsed Hemorrhoids for Treatment of Rectal Mucosa Prolapse following Anorectoplasty for Imperforate Anus

Surgical management of imperforate anus and rectal mucosal prolapse has evolved significantly over the last two decades. The procedure for prolapsed hemorrhoids (PPH) is now widely used primarily for rectal mucosal prolapse and internal hemorrhoids. We describe the use of PPH in the management of symptomatic rectal mucosal prolapse in a 39-year-old man with a history of a high imperforate anus and pelvic floor reconstruction. At 4-year follow up, the prolapse has not recurred and the preoperative symptoms have resolved. To the best of our knowledge, this is the first report on the use of a PPH in the management of rectal mucosal prolapse in a patient with these characteristics.

Systematic review and meta-analysis of randomized controlled trials comparing stapled haemorrhoidopexy with conventional haemorrhoidectomy

Background

This paper compares stapled haemorrhoidopexy with conventional haemorrhoidectomy for the treatment of haemorrhoids.

Methods

An electronic literature search was undertaken to identify primary studies and systematic reviews. Results on efficacy and safety were analysed. A meta-analysis was conducted to examine long-term outcomes.

Results

Twenty-nine randomized clinical trials recruiting 2056 patients were identified. Meta-analysis showed that stapled haemorrhoidopexy was less painful than conventional haemorrhoidectomy. Stapled haemorrhoidopexy required a shorter inpatient stay (weighted mean difference (WMD) − 0·95 (95 per cent confidence interval (c.i.) − 1·32 to − 0·59) days; P &lt; 0·001) and operating time (WMD − 11·42 (95 per cent c.i. − 18·26 to − 4·59) min; P = 0·001). It was also associated with a faster return to normal activities (WMD − 11·75 (95 per cent c.i. − 21·42 to − 2·08) days; P = 0·017). No significant difference was noted between the two techniques in terms of the total incidence of complications. Stapled haemorrhoidopexy was associated with a higher rate of recurrent disease (relative risk 2·29 (95 per cent c.i. 1·57 to 3·33); P &lt; 0·001).

Conclusion

Stapled haemorrhoidopexy offers some short-term benefits over conventional operation but the total complication rates are similar for both techniques. Stapled haemorrhoidopexy is associated with a higher rate of recurrent disease.

Long-term outcome of a multicentre randomized clinical trial of stapled haemorrhoidopexy versus Milligan-Morgan haemorrhoidectomy

INTRODUCTION

Stapled haemorrhoidopexy is less painful than Milligan-Morgan haemorrhoidectomy, allowing an earlier return to working activities, but its long-term efficacy is not fully established. This study reports the long-term follow-up of a randomized clinical trial comparing the two techniques in 100 patients affected by third- and fourth-degree haemorrhoids.

METHODS

All patients were contacted and invited to attend the clinic to assess long-term functional outcome. The degree of continence and satisfaction were assessed by questionnaire. Anal manometry and anoscopy were performed.

RESULTS

Eighty patients were available after a median follow-up of 87 months. No statistically significant differences were found between the two groups in terms of incontinence, stenosis, pain, bleeding, residual skin tags or recurrent prolapse. A tendency towards a higher recurrence rate was reported in patients with fourth-degree haemorrhoids, irrespective of the technique used. No significant changes in anal manometric values were found after surgery in either group.

CONCLUSION

Both techniques are effective in the long term.

Randomized comparison between stapled hemorrhoidopexy and Ferguson hemorrhoidectomy for grade III hemorrhoids in Taiwan: a prospective study

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.

Simple harmonic scalpel hemorrhoidectomy utilizing local anesthesia combined with intravenous sedation: a safe and rapid alternative to conventional hemorrhoidectomy

BACKGROUND

Harmonic Scalpel(R) hemorrhoidectomy (HSH) is an established surgical therapy for the treatment of symptomatic grade III and IV hemorrhoids. Hemorrhoid surgery is still being performed as an inpatient procedure with general or regional anesthesia in many centers today. There was a trend toward performing hemorrhoid surgery as an ambulatory procedure using local anesthesia supplemented with intravenous sedation. The aim of the current study was to evaluate the safety and efficacy of HSH performed with combination local anesthesia and intravenous sedation in an ambulatory surgical center.

MATERIALS AND METHODS

A retrospective review was performed on the clinical charts of all patients undergoing HSH in an ambulatory surgical center from 2001 to 2005. All hemorrhoidectomies were attempted under propofol/ketamine intravenous sedation and local anesthesia in the prone position. A simple, open technique without routine suture was used.

RESULTS

During the study period, 180 patients (70 females) underwent HSM. Mean procedure and total operating room time were 12 and 28 min, respectively. One patient (0.6%) was converted to general endotracheal anesthesia. Ten patients (5.6%) required post anesthesia care unit (PACU) observation. All patients were discharged home after the procedure. Postoperative complications occurred in 19 patients (10.6%). There were no reoperations and the total readmission rate was 3.7%.

CONCLUSION

HSH performed with a combination of intravenous sedation and local anesthesia is safe and effective in the ambulatory surgery setting. The combined technique was associated with a rate of complications comparable to published series utilizing conventional hemorrhoidectomy techniques. Added benefits include shorter hospital stay and a potential for cost savings.

[The surgical treatment of hemorrhoids]

Surgery is the most effective treatment in patients with symptomatic grade III-IV hemorrhoids who have not responded to outpatient treatment, when there is associated abnormalities (anal fissure, anal fistula, skin tags) and in thrombosed hemorrhoids. Hemorrhoidectomy is currently the "gold standard" treatment. Randomized controlled trials comparing open with closed hemorrhoidectomy show no significant differences in pain scores. Stapled hemorrhoidectomy produces less postoperative pain than hemorrhoidectomy but is less effective in terms of symptom control. No treatment is superior to others in reducing postoperative pain except the use of drugs and anesthetic techniques. In patients with prolapsed internal hemorrhoids and thrombosed hemorrhoids, treatment may initially consist of an urgent hemorrhoidectomy with the same results as those obtained with elective surgery.

Systematic review on the procedure for prolapse and hemorrhoids (stapled hemorrhoidopexy)

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.

A comparison of quality of life and postoperative results from combined PPH and conventional haemorrhoidectomy in different cases of haemorrhoidal disease

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.

[Results of Longo's stapled hemorrhoidectomy in ambulatory surgery for grade III-IV hemorrhoids]

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.

[Haemorrhoidal suffering]

Improvements in our understanding of the anatomy of haemorrhoids have prompted the development of new and innovative methods of treatment. Conservative treatment consists of dietary and lifestyle modifications. Standard interventional procedures in outpatient treatment are injection sclerotherapy and rubber band ligation. Among the surgical options for prolapsed haemorrhoids, formal haemorrhoidectomy now competes with stapled haemorrhoidopexy, which is less painful and allows shorter convalescence but may have a higher recurrence rate and needs further long-term evaluation.

Long-term results after stapled hemorrhoidopexy: high patient satisfaction despite frequent postoperative symptoms

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.

New techniques in the treatment of common perianal diseases: stapled hemorrhoidopexy, botulinum toxin, and fibrin sealant

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.

Stapled versus conventional surgery for hemorrhoids

BACKGROUND

Hemorrhoids are one of the most common anorectal disorders. The Milligan‐Morgan open hemorrhoidectomy is the most widely practiced surgical technique used for the management of hemorrhoids and is considered the current "gold standard". Circular stapled hemorrhoidopexy was first described by Longo in 1998 as alternative to conventional excisional hemorrhoidectomy. Early, small randomized‐controlled trials comparing stapled hemorrhoidopexy with traditional excisional surgery have shown it to be less painful and that it is associated with quicker recovery. The reports also suggest a better patient acceptance and a higher compliance with day‐case procedures potentially making it more economical. A previous Cochrane Review of stapled hemorrhoidopexy and conventional excisional surgery has shown that the stapled technique is associated with a higher risk of recurrent hemorrhoids and some symptoms in long term follow‐up. Since this initial review, several more randomized controlled trials have been published that may shed more light on the differences between the novel stapled approach and conventional excisional techniques.

OBJECTIVES

This review compares the use of circular stapling devices and conventional excisional techniques in the surgical treatment of hemorrhoids. Its goal is to ascertain whether there is any difference in the outcomes of the two techniques in patients with symptomatic hemorrhoids.

SEARCH STRATEGY

We searched all the major electronic databases (MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) from 1998 to December 2009.

SELECTION CRITERIA

All randomized controlled trials comparing stapled hemorrhoidopexy to conventional excisional hemorrhoidal surgeries with a minimum follow‐up period of 6 months were included.

DATA COLLECTION AND ANALYSIS

Data were collected on a data sheet. When appropriate, an Odds Ratio was generated using a random effects model.

MAIN RESULTS

Patients with SH were significantly more likely to have recurrent hemorrhoids in long term follow up at all time points than those with CH (12 trials, 955 patients, OR 3.22, CI 1.59‐6.51, p=0.001). There were 37 recurrences out of 479 patients in the stapled group versus only 9 out of 476 patients in the conventional group. Similarly, in trials where there was follow up of one year or more, SH was associated with a greater proportion of patients with hemorrhoid recurrence (5 trials, 417 patients, OR 3.60, CI 1.24‐10.49, p=0.02). Furthermore, a significantly higher proportion of patients with SH complained of the symptom of prolapse at all time points (13 studies, 1191 patients, OR 2.65, CI 1.45‐4.85, p=0.002). In studies with follow up of greater than one year, the same significant outcome was found (7 studies, 668 patients, OR 3.14, CI 1.20‐8.22, p=0.02). Patients undergoing SH were more likely to require an additional operative procedure compared to those who underwent CH (8 papers, 553 patients, OR 2.75, CI 1.31‐5.77, p=0.008). When all symptoms were considered, patients undergoing CH surgery were more likely to be asymptomatic (12 trials, 1097 patients, OR 0.59, CI 0.40‐0.88). Non significant trends in favor of SH were seen in pain, pruritis ani, and fecal urgency. All other clinical parameters showed trends favoring CH.