Stapled anopexy as a day surgery procedure: our experience over 400 cases

Prospective, Multicenter Randomized Controlled Trial Comparing Two Hemorrhoidopexy Staplers: The HEMOSTASIS Study

The objective of this study was to compare two hemorrhoidopexy staplers (EEA versus PPH03). Stapled hemorrhoidopexy is a treatment option for patients with symptomatic internal hemorrhoids who have failed more conservative measures. However, staple line bleeding remains common. Recent improvements in stapler design have attempted to reduce intraoperative bleeding and the need for intervention. HEMOSTASIS is a prospective, multicenter, 1:1 randomized controlled trial. Twelve hospital centers in the United States enrolled participants between 18 and 85 years of age with symptomatic grades 2 to 3 internal hemorrhoids. The primary end point was intraoperative bleeding, defined as bleeding requiring intervention (e.g., placement of sutures, cauterization, or ligation to achieve hemostasis). Secondary end points included staple line location, postoperative pain, quality of life, operative time, length of hospital stay, adverse events, and complication rates. On the primary end point, the rates of intraoperative bleeding requiring intervention were 41.0% (32 of 78) with EEA and 70.4% (50 of 71) with PPH (P < 0.001). Treatment for active bleeding was required in 30.8% versus 57.7% (P < 0.001) in the EEA and PPH arms, respectively. There were no significant differences between groups in postoperative pain. Adverse events and perioperative complication rates were generally mild/moderate and were similar between groups: 74.1% (60 of 81) of patients in the EEA group reported at least one adverse event versus 80.9% (55 of 68) in the PPH group (P = 0.32). Intraoperative bleeding occurred less often after stapled hemorrhoidopexy with the EEA stapler compared with the PPH03 stapler. Intervention to achieve hemostasis was required less often with the EEA stapler.

Guidelines for the treatment of hemorrhoids (short report)

Hemorrhoids are a common medical problem that is often considered as benign. The French Society of Colo-Proctology (Société nationale française de colo-proctologie [SNFCP]) recently revised its recommendations for the management of hemorrhoids (last issued in 2001), based on the literature and consensual expert opinion. We present a short report of these recommendations. Briefly, medical treatment, including dietary fiber, should always be proposed in first intention and instrumental treatment only if medical treatment fails, except in grade ≥III prolapse. Surgery should be the last resort, and the patient well informed of the surgical alternatives, including the possibility of elective ambulatory surgery, if appropriate. Postoperative pain should be prevented by the systematic implementation of a pudendal block and multimodal use of analgesics.

Circular mucosal anopexy: Experience and technical considerations

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.

Stapled hemorrhoidopexy: functional results, recurrence rate, and prognostic factors in a single center analysis

PURPOSE

Since its introduction, stapled hemorrhoidopexy (SHP), the so-called Longo procedure, became a widely accepted treatment option for prolapsing hemorrhoids. Nevertheless, from the early years, concerns grew about the early functional results and potential recurrences. In order to evaluate of SHP with special respect to early defecation disorders und recurrences, our single institute high-volume results were evaluated.

METHOD

One thousand one hundred forty-four consecutive patients with SHP for prolapsing hemorrhoids were evaluated in a period from January 2007 to December 2013. In a prospective analysis, patients were followed with special respect to postoperative complications, functional disorders, mainly perianal irritation, stenosis, and recurrence.

RESULTS

During the timeframe, a total of 663 men and 481 women were treated for prolapsing hemorrhoids. The mean age was 52.6 years (±14.4 years). Indication for surgery was prolapsing hemorrhoids in all cases. In addition to prolapse, 90 patients (7.9 %) suffered from bleeding, 96 patients (8.4 %) had itching, and 95 (8.3 %) had anal wetness; the mean operative time was 11 min (±4 min). Patients were treated as inpatients; the mean hospital stay was 3 days (±1 day). Early complications were observed in 14 patients (1.2 %). The follow-up revealed inflammatory reaction at the stapleline in 8 patients (0.7 %) and rectal stenosis in 22 cases (1.9 %), and recurrence was observed in 46 cases (4.0 %).

CONCLUSION

The data presented here provide evidence that SHP is a save procedure with a very low rate for functional disorders and low recurrence rate. Therefore, in our hands, SHP remains standard for prolapsing hemorrhoids.

Clinical application of procedure for prolapse and hemorrhoids

As the sliding anal cushion theory is widely accepted, the procedure for prolapse and hemorrhoids (PPH) has been applied all over the world. PPH mainly involves restoring the normal anatomy of the anal canal by circular excision of the mucosa above the hemorrhoids. Therefore, the blood supply is partially blocked so that hemorrhoids will gradually shrink. PPH has many advantages such as rapid rehabilitation, minimal invasiveness, and good short-term outcome (early resumption, less rectal bleeding and postoperative pain). However, many retrospective studies and meta-analyses indicate that, compared with the traditional surgery, PPH still has a number of deficiencies, including relatively high costs, high rates of relapse in a long term and so on. This review discusses the strategies, postoperative complications and clinical application of PPH.

Ambulatory haemorrhoidal surgery: systematic literature review and qualitative analysis

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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