Bile duct injury after laparoscopic cholecystectomy: resection of the entire extrahepatic biliary tree

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.

Prophylactic antibiotics for hemorrhoidectomy: are they really needed?

BACKGROUND

Hemorrhoidectomy is considered by many to be a contaminated operation that requires antibiotic prophylaxis to lower the incidence of surgical site infection. In reality, little evidence exists to either support or refute the use of antibiotic prophylaxis in this setting.

OBJECTIVE

This study aimed to determine if antibiotic prophylaxis is associated with reduced incidence of postoperative surgical site infection following hemorrhoidectomy.

DESIGN

This is a retrospective database review.

SETTING

This study was conducted at multiple institutions.

PATIENTS

All patients undergoing hemorrhoidectomy with minimum 3-month follow-up were included.

MAIN OUTCOME MEASURES

The primary outcome measure was the incidence of postoperative surgical site infection.

RESULTS

Eight hundred fifty-two patients met the inclusion criteria (50.1% female; mean age, 50.0 ± 13.7 years). The prevalence of preoperative risk factors for surgical site infection included 7.7% with a smoking history, 2.5% with diabetes mellitus, 0.8% receiving steroids, and 0.2% with Crohn's disease. Surgery was performed predominately for 3-column prolapsed internal and mixed internal/external hemorrhoidal disease. All surgeries performed were closed hemorrhoidectomies. Antibiotic prophylaxis was used in a fewer number of cases (41.3% vs 58.7%). Overall, there were only 12 documented postoperative infections identified, producing an overall incidence of 1.4%. Of those patients who developed postoperative surgical site infections, 9 (75%) did not receive antibiotic prophylaxis (p = 0.25). On multivariate regression analysis, no perioperative risk factor was associated with an increased risk of developing a posthemorrhoidectomy surgical site infection. Conversely, there were no adverse antibiotic-related complications such as Clostridium difficile colitis or antibiotic-associated diarrhea in those receiving antibiotic prophylaxis.

LIMITATIONS

This study was limited by the retrospective nature of the analysis.

CONCLUSIONS

Postoperative surgical site infection is an exceedingly rare event following hemorrhoidectomy. Antibiotic prophylaxis does not reduce the incidence of postoperative surgical site infection, and its routine use appears unnecessary.

Mid-term results of stapled hemorrhoidopexy for third- and fourth-degree hemorrhoids--correlation with the histological features of the resected tissue

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.