Long-term effects of stapled haemorrhoidectomy on internal anal function and sensitivity

The Italian Unitary Society of Colon-Proctology (Società Italiana Unitaria di Colonproctologia) guidelines for the management of acute and chronic hemorrhoidal disease

The aim of these evidence-based guidelines is to present a consensus position from members of the Italian Unitary Society of Colon-Proctology (Società Italiana Unitaria di Colon-Proctologia, SIUCP) on the diagnosis and management of hemorrhoidal disease, with the goal of guiding physicians in the choice of the best treatment option. A panel of experts was charged by the Board of the SIUCP to develop key questions on the main topics related to the management of hemorrhoidal disease and to perform an accurate and comprehensive literature search on each topic, in order to provide evidence-based answers to the questions and to summarize them in statements. All the clinical questions were discussed by the expert panel in multiple rounds through the Delphi approach and, for each statement, a consensus among the experts was reached. The questions were created according to PICO (patients, intervention, comparison, and outcomes) criteria, and the statements were developed adopting the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) methodology. In cases of grade 1 hemorrhoidal prolapse, outpatient procedures including hemorrhoidal laser procedure and sclerotherapy may be considered the preferred surgical options. For grade 2 prolapse, nonexcisional procedures including outpatient treatments, hemorrhoidal artery ligation and mucopexy, laser hemorrhoidoplasty, the Rafaelo procedure, and stapled hemorrhoidopexy may represent the first-line treatment options, whereas excisional surgery may be considered in selected cases. In cases of grades 3 and 4, stapled hemorrhoidopexy and hemorrhoidectomy may represent the most effective procedures, even if, in the expert panel opinion, stapled hemorrhoidopexy represents the gold-standard treatment for grade 3 hemorrhoidal prolapse.

Tissue-selecting-technique mega-window stapler combined with anal canal epithelial preservation operation in prolapsed hemorrhoids

OBJECTIVE

This study aimed to compare the efficiency of these two combined surgeries [prolapse and hemorrhoids (PPH) combined with the external hemorrhoidectomy and inferior internal hemorrhoid ligation; tissue selecting technique with mega-window stapler (TST-MS) combined with anal canal epithelial preservation operation].

METHODS

This is a single-center, evaluator-blinded randomized controlled trial (RCT). A total of 204 participants were randomly divided into the two groups. The anal function, reoccurrence, intraoperative variables, and operative complications were assessed. The measurement data were compared by paired t test and rank sum test. Chi-squared or Fisher's exact test was used for count data and rank sum test for ranked data. To assess differences within each group in different time points, the repeated-measures analysis of variance was conducted.

RESULTS

TST-MS combined with anal canal epithelial preservation operation had lower Wexner score of anal incontinence (Z = 3.062, P = 0.002), higher patients' satisfaction degree (t = 7.32, P < 0.001), less residual skin tags (χ² = 18.141, P < 0.001), longer operative time (Z = -2.281, P = 0.023), and bigger volume of excised rectal mucosa (t = 2.35, P = 0.020). There was no significant difference between the two groups in the anal canal circumference, recurrence, intraoperative blood loss, weight of excised rectal mucosa, anal pain, bleeding, urinary retention, anal edge edema, and anatomical anal stenosis (all P > 0.05).

CONCLUSIONS

TST-MS combined with anal canal epithelial preservation operation showed better clinical efficiency in the treatment of prolapsed hemorrhoids.

TRIAL REGISTRATION

This study has been registered in Chinese Clinical Trial Registry (ChiCTR2000038533).

Ultrasound Imaging of the Pelvic Floor

This article discusses the background and appraisal of endoluminal ultrasound of the pelvic floor. It provides a detailed anatomic assessment of the muscles and surrounding organs of the pelvic floor. Different anatomic variability and pathology, such as prolapse, fecal incontinence, urinary incontinence, vaginal wall cysts, synthetic implanted material, and pelvic pain, are easily assessed with endoluminal vaginal ultrasound. With pelvic organ prolapse in particular, not only is the prolapse itself seen but the underlying cause related to the anatomic and functional abnormalities of the pelvic floor muscle structures are also visualized.

A Randomized Controlled Trial Comparing Suture-Fixation Mucopexy and Doppler-Guided Hemorrhoidal Artery Ligation in Patients with Grade III Hemorrhoids

Background. We aimed to evaluate the effectiveness of a suture-fixation mucopexy procedure by comparing with Doppler-guided hemorrhoidal artery ligation (DGHAL) in the management of patients with grade III hemorrhoids. Methods. This was a randomized controlled trial. One hundred patients with grade III hemorrhoids were randomly assigned to receive suture-fixation mucopexy (n = 50) or DGHAL (n = 50). Outcome assessments were performed at 2 weeks, 12 months, and 24 months. Assessments included resolution of clinical symptoms, postoperative complications, duration of hospitalization, and total costs. Results. At 2 weeks, one (2%) patient in suture-fixation group and four (8%) patients in DGHAL group had persistent prolapsing hemorrhoids. Postoperative bleeding was observed in two patients (4%) in suture-fixation group and one patient in DGHAL group. There was no significant difference in short-term recurrence between groups. Postoperative complications and duration of hospitalization were comparable between the two groups. Rates of recurrence of prolapse or bleeding at 12 months did not differ between groups. However, recurrence of prolapse at 24 months was significantly more common in DGHAL group (19.0% versus 2.3%, p = 0.030). Conclusions. Compared with DGHAL, the suture-fixation mucopexy technique had comparable short-term outcomes and favorable long-term outcomes.

Short- and long-term results of harmonic scalpel hemorrhoidectomy versus stapler hemorrhoidopexy in treatment of hemorrhoidal disease

PURPOSE

In this prospective randomized study, our aim is to compare the short- and long-term results of harmonic scalpel hemorrhoidectomy (HSH) and stapler hemorrhoidopexy (SH) methods in the surgical treatment of Grade III and Grade IV hemorrhoidal disease.

METHODS

Ninety-nine consecutive patients diagnosed with Grade III or Grade IV internal hemorrhoidal disease were included in the study. Patients were randomized to HSH (n = 48) or SH (n = 51) treatments. Data on patient demographic and clinical characteristics, operative details, postoperative pain score on a visual analog scale, additional analgesic requirement, postoperative short- and long-term complications, and recurrence of hemorrhoidal disease were also recorded. Patients were regularly followed for a total period of 24 (6-36) months.

RESULTS

The patient demographic and clinical characteristics were similar in the two groups. The operative time was significantly shorter in the HSH group compared with the SH group. Overall pain scores were not significantly different between the groups, although severe pain was significantly more common in the HSH group. Recurrence was significantly lower in the HSH group compared with the SH group.

CONCLUSION

HSH and SH are both safe and effective methods for surgical treatment of Grade III and Grade IV hemorrhoidal disease. In our study, the HSH method was determined to be safer, easier, and faster to perform, and associated with fewer long-term recurrences than the SH method.

Internal anal sphincter augmentation and substitution

There is an increasing recognition of the importance of internal anal sphincter (IAS) dysfunction presenting as passive faecal incontinence. This problem may manifest after anal sphincterotomy or following the more minimally invasive operations for haemorrhoids, as well as with advancing age. Because of the poor results of IAS plication and the beneficial outcomes with peri-urethral bulking agents in urology, these materials have been developed for use in IAS dysfunction. This review outlines the basic purported mechanisms of action, defining the materials in clinical use, their methods of deployment, complications and reported outcomes. There is still much that is unknown concerning the ideal agent or the volume and the technique of deployment, which will only be answered by powerful, prospective, randomized, controlled trials. The specific role of autologous stem cells designed to regenerate the sphincters in cases of functional impairment or muscle loss is yet to be seen.

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.

Conservative and surgical treatment of haemorrhoids

The management of haemorrhoids has evolved rapidly during the past few decades. Several new treatments have been proposed with the aim of reducing patients' postoperative pain, time to return to normal life, risk of early and late complications, and recurrence rate. Although conservative treatment based on dietary and lifestyle changes can help the majority of patients, and rubber band ligation and phlebotonic drugs can effectively treat grade I and II haemorrhoids, surgery is required for the most advanced stages. Milligan-Morgan haemorrhoidectomy is considered to be the gold-standard approach for grade IV haemorrhoids. An increasing number of minimally invasive treatment options, including mucopexy with or without mucosal resection and haemorrhoid artery ligation, have now been proposed for the management of grade III haemorrhoids. These approaches aim to correct the underlying pathophysiological mechanisms involved in the aetiology of haemorrhoids. An increased risk of recurrence is the price to pay for these minimally invasive and less painful treatments, but the sparing of the sensitive anoderm and a rapid return to normal life without pain are greatly appreciated by patients. An algorithm for the management of haemorrhoids using evidence-based medicine is also presented here.

Doppler-guided hemorrhoid artery ligation with Recto-Anal-Repair modification: functional evaluation and safety assessment of a new minimally invasive method of treatment of advanced hemorrhoidal disease

Purpose: We present 12-month followup results of functional evaluation and safety assessment of a modification of hemorrhoidal artery ligation (DGHAL) called Recto-Anal-Repair (RAR) in treatment of advanced hemorrhoidal disease (HD). Methods: Patients with grade III and IV HD underwent the RAR procedure (DGHAL combined with restoration of prolapsed hemorrhoids to their anatomical position with longitudinal sutures). Each patient had rectal examination, anorectal manometry, and QoL questionnaire performed before 3 months, and 12 months after RAR procedure. Results: 20 patients completed 12-month followup. There were no major complications. 3 months after RAR, 5 cases of residual mucosal prolapse were detected (25%), while only 3 patients (15%) reported persistence of symptoms. 12 months after RAR, another 3 HD recurrences were detected, to a total of 8 patients (40%) with HD recurrence. Anal pressures after RAR were significantly lower than before (P < 0.05), and the effect was persistent 12 months after RAR. One patient (5%) reported occasional soiling 3 months after RAR. Conclusions: RAR seems to be a safe method of treatment of advanced HD with no major complications. The procedure has a significant influence on anal pressures, with no evidence of risk of fecal incontinence after the operation.

A one-year follow-up of the quality of life after stapled hemorrhoidopexy

Articles presenting treatment outcomes of stapled hemorrhoidopexy are rarely based on detailed analyses of the quality of life.The aim of the study was the assessment of changes within one year of treatment in the quality of life of patients who underwent stapled hemorrhoidopexy using QLQ-C30 form (version 3).

MATERIAL AND METHODS

120 patients with grade III and IV internal hemorrhoidal disease treated with stapled hemorrhoidopexy were enrolled in the study. They answered questions from QLQ-C30 form and were subjected to examination a day before surgery and 1 day, 7 days, 4 weeks, 6 and 12 months after surgery. Assessment included operation site inspection, pain intensity measurement in VAS scale and parameters incorporated in QLQ-C30 form evaluation.

RESULTS

The overall quality of life decreased immediately after surgery (a day after 50% vs. 60% before surgery), but rapidly improved in one week and in one month periods (60% and 80% consecutively) reaching a plateau one month after surgery. Early complications occurred in 6 patients (5%). Recurrence of the disease was not observed. Bleeding from anastomosis site and severe pain in anal area immediately post surgery as a result of improper purse-string suture placement were the main complications.

CONCLUSIONS

In patients with grade III or IV hemorrhoidal disease, stapled hemorrhoidopexy ensures a rapid improvement in the quality of life after surgery to the level experienced prior to the operation. 7-day convalescence period is sufficient. After one month, the overall quality of life improves significantly and reaches a plateau.

Clinical outcomes of stapled transanal rectal resection (STARR) for obstructed defecation syndrome (ODS): a single institution experience in South Korea

PURPOSE

The purpose of this study was to assess both the short- and long-term functional outcomes of stapled transanal rectal resection (STARR) in ODS patients.

PATIENTS AND METHODS

We performed a retrospective review of data that were collected from January 2005 to October 2008. Between January 2005 to June 2006, 58 patients who underwent STARR were enrolled in this study. Follow-up was scheduled for 3 months and 1 year after surgery with the Cleveland Clinic Florida (CCF) constipation score and satisfaction grade. To evaluate the long-term functional outcome, we interviewed the patients by telephone using questionnaires for the CCF score and satisfaction grade on October 2008.

RESULTS

The median follow-up period was 34 months (range, 27-46 months). The mean age and sex ratio were 54 years (range, 19-85 years) and 8:50 (M/F). The mean CCF constipation scores were 17.6 before the surgery, 9.5 at 3 months, 9.6 at 12 months, and 10.3 at the time of the latest interview. The satisfaction grade, which was rated as excellent and good by 63.4% of the patients at the time of the latest interview, was worse than that at 3 months (37.8%). Among the cases of the excellent group (19 cases) at postoperative 3 months, 13 cases (68.4%) were classified as excellent or good at the time of the latest interview.

CONCLUSION

The STARR is a safe and effective surgical procedure for restoring the anatomy and function in ODS patients. Strict selection of patients is needed in enhancing and maintaining the patients' satisfaction after the procedure.

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.

Stapled haemorrhoidopexy transiently decreases rectal compliance and sensitivity

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.

Fecal urge incontinence after stapled anopexia for prolapse and hemorrhoids: a prospective, observational study

BACKGROUND

Stapled anopexia was introduced as a surgical method in 1993. Long-term data with special interest in functional results and relapse symptoms are rarely presented. Urinary discomfort and problems with fecal urge incontinence are addressed as severe side effects. We present our long-term results (using data from a high-volume center) with this technique and two surgeons' experience.

METHODS

During 4 years, a total of 546 patients entered the study. For long-term evaluation, 452 patients (237 women and 215 men) were available (82.9%). Patients with recurrent hemorrhoidal prolapse and fecal incontinence were excluded. Postoperative reevaluation with physical condition was performed after 1, 6, and 24 months by means of manometry, rectoscopy, and SF-36 Health Survey Test.

RESULTS

Early postoperative urinary impairment was 7.3%. Early fecal urge incontinence rate was 3.3%. Overall perioperative complication rate was 11.1%. Within 1 month, the rate of fecal urge incontinence increased to 13.5% and decreased to 4% and 2.9% after a period of 6 and 24 months. Overall recurrence rate was 3.3%. Reoperation rate according to the primary indication was 2.9% after 24 months. The SF-36 data showed a return to normal 1 month after the procedure was performed. Overall satisfaction rate was 95.4%.

CONCLUSIONS

Our study demonstrates that stapled anopexia is a safe and secure procedure for treatment of hemorrhoidal prolapse. Fecal urge incontinence is a self-limiting side effect that with which patients need to be made familiar.

Prospective multicentre clinical trial of stapled transanal rectal resection for obstructive defaecation syndrome

BACKGROUND

This prospective multicentre study assessed the safety and effectiveness of stapled transanal rectal resection (STARR) for treatment of obstructive defaecation syndrome (ODS).

METHODS

Between February 2001 and June 2006, 104 patients diagnosed with ODS were treated with STARR. Follow-up was scheduled for 1, 3 and 6 months after surgery, and annually thereafter. Variables related to the patient, surgical technique and outcome were analysed.

RESULTS

Mean operating time was 46.7 min. Haemorrhage at the staple line occurred in 55 patients (52.9 per cent). Three patients required surgical revision in the first 48 h owing to persistent bleeding. The median postoperative pain score was 2.4 on a scale from 1 to 10. Mean hospital stay was 2.2 days. The mean constipation score improved from 13.5 before surgery to 5.1 at 1-year follow-up (P = 0.006). Twenty-three patients reported faecal incontinence at 4 weeks after surgery, but only nine still had minor residual incontinence by 1 year. At a median follow-up of 26 (range 12-72) months, ODS had recurred or persisted radiologically and/or clinically in 11 patients.

CONCLUSION

STARR is associated with low morbidity and a short hospital stay, and is an effective alternative treatment for ODS.

Continence disorders after anal surgery--a relevant problem?

SUBJECT

Anal incontinence is a well-known and feared complication following surgery involving the anal sphincter, particularly if partial transection of the sphincter is part of the surgical procedure.

METHODS

The literature was reviewed to evaluate the risk of postoperative incontinence following anal dilatation, lateral sphincterotomy, surgery for haemorrhoidal disease and anal fistula.

RESULTS

Various degrees of anal incontinence are reported with frequencies as follows: anal dilatation 0-50%, lateral sphincterotomy 0-45%, haemorrhoidal surgery 0-28%, lay open technique of anal fistula 0-64% and plastic repair of fistula 0-43%. Results vary considerably depending on what definition of "incontinence" was applied. The most important risk factors for postoperative incontinence are female sex, advanced age, previous anorectal interventions, childbirth and type of anal surgery (sphincter division). Sphincter lesions have been reported following procedures as minimal as exploration of the anal canal via speculum.

CONCLUSIONS

Continence disorders after anal surgery are not uncommon and the result of the additive effect of various factors. Certain risk factors should be considered before choosing the operative procedure. Since options for surgical repair of postoperative incontinence disorders are limited, careful indications and minimal trauma to the anal sphincter are mandatory in anal surgery.

Evaluation of rectal sensory and motor function by means of the electronic barostat after stapled hemorrhoidopexy

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.

Circular stapled hemorrhoidopexy: experience of a single center with 445 cases

This study was designed to review the results of circular stapled hemorrhoidopexy (CSH) in the management of second-, third-, and fourth-degree hemorrhoidal disease. The medical records of 483 patients who had undergone circular stapled hemorrhoidopexy for symptomatic hemorrhoidal disease from June 2001 to September 2006 were evaluated. Data regarding complications, residual symptoms, and recurrence were collected. The study included 445 patients (283 men, 162 women) between 22 and 74 years old (median age 39 years). This constituted 92% of all patients. Concomitant lateral internal sphincterotomy, skin tags' excision, and thrombus removal were done in 106 (24.0%), 83 (18.5%), and 20 (4.5%) patients, respectively. The median operating time was 24 minutes (10-45 minutes). The median hospital stay was 40 hours (11-72 hours). Complications during the first 24 hours were fecal urgency (25%), urinary retention (8%), and rectal bleeding (1%). Pruritus ani (21%), thrombosed external hemorrhoids (4%), staple line stenosis (2%), rectal bleeding (2%), anal fissure (1%), and persistent skin tags (3%) were the symptoms seen during the long-term follow-up. The median follow-up was 23 months (6-70 months). The recurrence rate was 1%. Circular stapled hemorrhoidopexy can be safely performed with low recurrence and complication rates while offering a relatively painless postoperative period for the patient.

Stapled anopexy: postoperative course and functional outcome in 400 patients

PURPOSE

We performed a retrospective analysis of postoperative course and functional outcome after at least six months' follow-up in a series of 400 consecutive patients who underwent stapled anopexy.

METHODS

All patients were evaluated at one week and one month after surgery and then according to symptoms. A clinical or telephone follow-up was obtained for all patients. The last 50 patients were prospectively evaluated with an obstructive defecation syndrome score and Wexner continence and constipation score before operation and six months after anopexy.

RESULTS

There were no intraoperative complications. Postoperative bleeding that requires reoperation was observed in 11 patients, most cases (9/11) occurring in the early experience (first 50 patients). After a median follow-up of 6.1 years, four patients required reoperation. After anopexy, we observed an improvement in patients who present disturbance in defecation. The difference between the median obstructive defecation syndrome score before and after operation was statistically significant. Wexner score showed improvement without significant difference.

CONCLUSIONS

Treatment of hemorrhoids with circular stapler seems to be effective with low morbidity and high satisfaction rate because of reduced postoperative pain and rapid recovery. This technique also allows improvement of obstructive defecation symptoms, which are seldom studied in patients with hemorrhoids.

Postoperative complications after procedure for prolapsed hemorrhoids (PPH) and stapled transanal rectal resection (STARR) procedures

Procedure for prolapsing hemorrhoids (PPH) and stapled transanal rectal resection for obstructed defecation (STARR) carry low postoperative pain, but may be followed by unusual and severe postoperative complications. This review deals with the pathogenesis, prevention and treatment of adverse events that may occasionally be life threatening. PPH and STARR carry the expected morbidity following anorectal surgery, such as bleeding, strictures and fecal incontinence. Complications that are particular to these stapled procedures are rectovaginal fistula, chronic proctalgia, total rectal obliteration, rectal wall hematoma and perforation with pelvic sepsis often requiring a diverting stoma. A higher complication rate and worse results are expected after PPH for fourth-degree piles. Enterocele and anismus are contraindications to PPH and STARR and both operations should be used with caution in patients with weak sphincters. In conclusion, complications after PPH and STARR are not infrequent and may be difficult to manage. However, if performed in selected cases by skilled specialists aware of the risks and associated diseases, some complications may be prevented.

Postoperative complications after procedure for prolapsed hemorrhoids (PPH) and stapled transanal rectal resection (STARR) procedures

Procedure for prolapsing hemorrhoids (PPH) and stapled transanal rectal resection for obstructed defecation (STARR) carry low postoperative pain, but may be followed by unusual and severe postoperative complications. This review deals with the pathogenesis, prevention and treatment of adverse events that may occasionally be life threatening. PPH and STARR carry the expected morbidity following anorectal surgery, such as bleeding, strictures and fecal incontinence. Complications that are particular to these stapled procedures are rectovaginal fistula, chronic proctalgia, total rectal obliteration, rectal wall hematoma and perforation with pelvic sepsis often requiring a diverting stoma. A higher complication rate and worse results are expected after PPH for fourth-degree piles. Enterocele and anismus are contraindications to PPH and STARR and both operations should be used with caution in patients with weak sphincters. In conclusion, complications after PPH and STARR are not infrequent and may be difficult to manage. However, if performed in selected cases by skilled specialists aware of the risks and associated diseases, some complications may be prevented.

Postoperative complications after procedure for prolapsed hemorrhoids (PPH) and stapled transanal rectal resection (STARR) procedures

Procedure for prolapsing hemorrhoids (PPH) and stapled transanal rectal resection for obstructed defecation (STARR) carry low postoperative pain, but may be followed by unusual and severe postoperative complications. This review deals with the pathogenesis, prevention and treatment of adverse events that may occasionally be life threatening. PPH and STARR carry the expected morbidity following anorectal surgery, such as bleeding, strictures and fecal incontinence. Complications that are particular to these stapled procedures are rectovaginal fistula, chronic proctalgia, total rectal obliteration, rectal wall hematoma and perforation with pelvic sepsis often requiring a diverting stoma. A higher complication rate and worse results are expected after PPH for fourth-degree piles. Enterocele and anismus are contraindications to PPH and STARR and both operations should be used with caution in patients with weak sphincters. In conclusion, complications after PPH and STARR are not infrequent and may be difficult to manage. However, if performed in selected cases by skilled specialists aware of the risks and associated diseases, some complications may be prevented.

Impact of stapled haemorrhoidopexy on stool continence and anorectal function: long-term follow-up of 242 patients

BACKGROUND AND AIMS

Several studies have proved the feasibility and safety of stapled anopexy for treating haemorrhoidal prolapse. However, stool urgency and faecal incontinence as possible side effects are still debated. Therefore, the present study was designed to assess the impact of Longo's procedure on stool continence and anorectal function.

MATERIALS AND METHODS

From 1999 to 2005, 300 patients underwent stapled haemorrhoidopexy for symptomatic haemorrhoidal prolapse. Two hundred forty-two patients (100 women, 142 men) were available for follow-up and were retrospectively reviewed. All operations were performed by one single surgeon. To evaluate anorectal function, the results of a validated incontinence score (total incontinence score [IS]: 0 = best, 20 = worst) and evacuation score (total evacuation score [ES]: 0 = worst, 28 = best) were compared pre- and postoperatively.

RESULTS

The total IS showed no difference in means before and after operation (p = 0.875, CI 95%) retrospectively. Concerning the ES, paired sample t-test showed a weak positive correlation, indicating a significant difference in score means (p = 0.041, CI 95%). The group means changed from 26.24 before operation to 26.60 after the follow-up period.

CONCLUSION

The present data revealed no significant negative impact of Longo's technique on anorectal function. In contrast, according to the evacuation score, the results showed a significant improvement of evacuation.

Evaluation of the use of PTQ implants for the treatment of incontinent patients due to internal anal sphincter dysfunction

OBJECTIVE

This study reports the results of injectable silicone PTQ implants for faecal incontinence due to internal anal sphincter (IAS) dysfunction.

METHOD

Twenty patients (12 women) with partial faecal incontinence aged from 55 to 65 years were treated by a PTQ implant. All patients completed the Cleveland Clinic Continence and Quality of Life questionnaire. Endoluminal ultrasound and anorectal physiological testing were performed in each patient. All implants were inserted into the submucosal plane without ultrasound guidance.

RESULTS

Faecal continence was significantly improved up to 1 year. The Wexner continence score fell from a median of 13.05 (range, 5-20) before treatment to 4.5 (range 2-7.7) at 1 month after (P < 0.005). This rose gradually to 6.2 (range, 0-16) at one year (P = 0.02) and 9.4 (range, 1-20) at 2 years (P = 0.127). There were no differences in resting or squeeze pressure before and at 3 months after treatment (P = 0.86 and P = 0.93). Fourteen (70%) patients experienced pruritus ani during the first few weeks after the procedure and one developed infection at the implant site.

CONCLUSION

Silicone implantation is minimally invasive and technically simple. It is effective over 1 year in the treatment of faecal incontinence due to IAS dysfunction.

Initial experience with stapled hemorrhoidopexy for treatment of hemorrhoids

BACKGROUND

Introduction of stapled hemorrhoidopexy by Longo in 1998 represented a radical change in the treatment of hemorrhoids. By avoiding multiple excisions and suture lines in the perianal region, stapled hemorrhoidopexy is intended to offer less postoperative pain than with conventional techniques.

OBJECTIVE

To report and analyze the intra and postoperative results gained during initial experience with stapled hemorrhoidopexy.

METHODS

One hundred and fifty five patients (67 males) with average age of 39.5 years (21-67 years) underwent stapled hemorrhoidopexy between June 2000 and December 2003 with symptomatic third-degree (n = 74) and fourth-degree (n = 81) hemorrhoids. Mean follow-up period was 20 months (14-60 months).

RESULTS

Preoperative symptoms were prolapse (96.7%) and anal bleeding (96.1%). Overall mean operative time was 23 minutes (16-48 minutes). We observed one case of stapler failure and one case of failure to introduce the stapler occurred in a patient with previous anal surgery. Additional sutures for hemostasis were required in 103 patients (66.5%). Resection of skin tags was performed in 45 cases (29%). Postoperatively scheduled analgesia with oral dipyrone and celecoxib was enough for pain control in 131 patients (84.5%). Rescue analgesia was necessary in 24 cases (15.5%). Five patients needed opiates for pain control. Hospital discharge took place on the first postoperative day in 140 patients (90.3%). First defecation without pain was reported by 118 patients (76.1%). Postoperative complications were anal bleeding (10.3%), severe pain (3.2%), urinary retention (3.9%), fever without any signs of perianal infection (1.9%), incontinence for flatus (1.9%), hemorrhoidal thrombosis (1.3%). Two patients presented symptoms of recurrent hemorrhoidal disease and were successfully treated by conventional hemorrhoidectomy. They were no cases of anal stenosis, permanent incontinence, chronic pain or deaths in this series.

CONCLUSIONS

Hemorrhoidopexy can be considered a feasible and safe alternative technique to conventional hemorroidectomy for select patients.

Efeito da nifedipina gel 0,2% nas pressões de canal anal e na dor pós-operatória: estudo após hemorroidectomia pela técnica aberta

INTRODUÇÃO: As hemorróidas são muito freqüentes e após o seu tratamento cirúrgico tem se observado que a dor causa muito sofrimento. Várias alternativas tem sido estudadas para melhorar a dor pós-operatória dentre elas a esfincterotomia cirúrgica que pode em alguns casos causar algum grau de incontinência fecal. Por esse motivo vários estudos tem utilizado a esfincterotomia química com nifedipina, diltiazen, trinitrato de glicerina e toxina botulínica. O objetivo dessa pesquisa foi avaliar o efeito da nifedipina tópica nas diminuições das pressões do canal anal e consequente influência na melhora da dor pós-operatória. MATERIAL E MÉTODO: Utilização da nifedipina tópica gel 0,2% (Grupo 1) e lidocaina 2% (Grupo 2) no pós operatório de hemorroidectomia aferindo as pressões no pré, primeiro, quarto e sétimo dias de pós operatório, associado de medida de dor todos os dias do pós-operatório através de tabela analógica. RESULTADOS: Os autores não encontraram diferenças em relação às pressões de canal anal mas em relação à dor referida estas foram em menor intensidade no grupo que recebeu a nifedipina. CONCLUSÕES: a nifedipina gel foi eficiente na analgesia pós-operatória, no entanto não alterou as pressões do canal anal.

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.

A prospective evaluation of stapled haemorrhoidopexy/rectal mucosectomy in the management of 3rd and 4th degree haemorrhoids

OBJECTIVE

We have audited our 5 years experience of circumferential-stapled haemorrhoidopexy (PPH).

METHOD

A prospectively collected electronic data base of our 5-year experience to September 2005 has been examined.

RESULTS

A total of 357 consecutive patients (220 - 62% women, median age 46 years; range 28-92) with symptomatic third- and fourth-degree haemorrhoids (ratio 222:135) have undergone a stapled haemorrhoidopexy/rectal mucosectomy. One hundred and thirty-two (37%) had failed previous banding; 42 (12%) had undergone a Milligan-Morgan haemorrhoidectomy in the past. All but one was performed under general anaesthetic. Mean duration of surgery was 15 min (range 11-40); 299 (84%) were planned day cases (three patients were admitted overnight for pain relief (2) and retention of urine) and 57 were planned successful overnight stays. Reactive postoperative bleeding requiring a blood transfusion occurred in three patients (0.8%): one returned to theatre (0.2%). Three patients (0.8%) had a secondary haemorrhage requiring a hospital visit, one was admitted overnight. Four patients complaining of severe pain were managed in the community. Transient urgency was reported in 92 patients (26%); 58 (63%) were men, faecal impaction 4 (1.1%), minor staple line stenosis requiring dilatation 5 (1.4%), peri-anal sepsis from an associated untreated chronic anal fissure 1 (0.2%). Normal work was resumed between 3 and 31 days (median 7). Five patients re-presented with recurrent symptoms between 14 & 18 months: further treatment comprised a repeat PPH in three (one was very painful), banding 1 and reassurance alone. A further patient re-presented with minor soiling which responded to physiotherapy.

CONCLUSION

Stapled haemorrhoidopexy/rectal mucosectomy is a safe, effective and predictable treatment of third- and fourth- degree haemorrhoids and in the majority of patients can be carried out on a day case basis.

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.

Evaluation of the stapled transanal rectal resection technique with two staplers in the treatment of obstructive defecation syndrome

BACKGROUND

This study was designed to assess the safety and effectiveness of stapled transanal rectal resection (STARR) and to compare the results of two staplers.

STUDY DESIGN

From February 2001 to June 2005, 37 patients diagnosed with obstructive defecation syndrome were treated with the STARR technique. We analyzed variables related to the patient, diagnosis based on anorectal exploration, surgical technique used, and clinical and radiologic results. We compared these results in patients with procedure prolapsed hemorrhoids (PPH)33-01 (group 1, n = 17) or PPH33-03 (group 2, n = 20). The patients were followed postoperatively at 1, 3, and 6 months, and annually.

RESULTS

Intraoperative hemorrhage at the stapled suture occurred in 13 patients from group 1 and in 6 patients from group 2 (p = 0.03). The degree of postoperative pain was not different between the two groups. During the followup period, radiologic and clinical correction of the rectocele and intussusception was found in 94.6% of the patients, with a recurrence in 1 patient from each group. One patient from group 1 developed stenosis of the anastomosis, which improved with digital dilatations. Six patients from group 1 and none from group 2 (p < 0.05) had granulomas on the staple line at the sites of the reabsorbable reinforcing stitches, which were related to postoperative bleeding and anal discomfort.

CONCLUSIONS

STARR is an effective alternative for treatment of obstructive defecation syndrome, with a low morbidity and a shorter hospital stay. The use of PPH33-03 instead of PPH33-01 decreases the risk of hemorrhagic complications and enables more secure implantation as an outpatient procedure.

Injectable silicone biomaterial (PTQ) to treat fecal incontinence after hemorrhoidectomy

PURPOSE

Passive fecal incontinence after hemorrhoidectomy may occur and is socially incapacitating. There has been no effective treatment for passive fecal incontinence caused by internal anal sphincter dysfunction. This case series reviewed the outcome of therapy with injectable silicone biomaterial (PTQ) in patients who had passive fecal incontinence after hemorrhoidectomy.

METHODS

From 2003 to 2004, seven patients referred with passive fecal incontinence after hemorrhoidectomy (Milligan-Morgan hemorrhoidectomy n = 5; stapled hemorrhoidectomy n= 2) were treated with injectable PTQ implants. All were assessed with anorectal physiology testing, Wexner continence score, and objective quality of life questionnaires before and after treatment.

RESULTS

The Wexner continence score improved significantly at three months (P= 0.016) after the injectable PTQ implant and continued to improve significantly for up to 12 months (P = 0.016). The global quality of life scores (Visual Analog Scale) showed similar improvement (P = 0.016 at 3 months; P = 0.016 at 12 months). Three domains (life style, coping behavior, and depression/self-perception) of Fecal Incontinence Quality of Life Scale were significantly improved. The manometric studies showed significant improvement in maximum resting anal canal pressures (P= 0.016) after the injectable PTQ implant.

CONCLUSIONS

The injectable silicone biomaterial is an effective treatment for passive fecal incontinence after hemorrhoidectomy providing good medium-term improvement in fecal incontinence and fecal incontinence-related quality of life.

[Postoperative pain and long-term results after hemorrhoidal treatment with anopexy]

AIMS

Anopexy allows treatment of hemorrhoidal symptoms with a less painful postoperative course. This information is important for the patient, but may lead to dissatisfaction if pain level is higher than expected. To evaluate perceived pain and physical limitation levels in relation to patient's expectation. Evaluate long-term functional results.

RESULTS

Sixty-eight consecutive patients (56 males) were prospectively included. Distribution of haemorrhoid grades were 4 grade 2 (6%), 52 grade 3 (76%) and 12 grade 4 (18%). Postoperative pain level was less or equal than expected for 85% of patients, with a better acceptance superior to 45 years. Physical limitation was equally or less important than expected for 89%. At the 32 weeks follow-up hemorrhoidal symptoms were present in 23%, uninfluenced by any patient's or operative characteristics. Incontinence with urgency was reported by 17%. Presence of an alliterated continence was linked to stapled line inferior to 6,5 mm from pectineate line, doughnut height inferior to 22 mm, external hemorrhoids and related to surgeon.

CONCLUSION

Pragmatic information, although vague, about postoperative pain does not expose to patient's dissatisfaction. Functional results are not influenced by technical variation. Continence alterations are not severe, but frequent when stapled line is too close from pectineate line.

Complications and recurrence after excision of rectal internal mucosal prolapse for obstructed defaecation

BACKGROUND

Rectal internal mucosal prolapse (RIMP) may cause obstructed defaecation and encouraging short-term results have been reported after its transanal excision. The objective of this retrospective study was to assess both clinical and functional outcome after this procedure alone for patients presenting with evacuatory difficulty.

PATIENTS AND METHODS

Forty patients (30 females, mean age 54 years), all suffering from obstructed defaecation, underwent RIMP excision at our unit during the last 11 years. RIMP was of first degree in three patients, of second degree in 21, and of third degree in 16 with 28/40 cases (70%) having associated anorectal pathology. The operation was carried out by hand suture (submucosal excision, Sarles endorectal excision, or the Delorme mucosectomy) in 26 patients, by circular stapled prolapsectomy in nine patients, or by combined manual and stapled techniques in five cases. Proctoscopy was carried out after 2 months for all patients, with anorectal manometry in 30 patients. Patients were independently assessed by state-trait anxiety scales for attendant anxiety and depression.

RESULTS

Eighteen patients (45%) had significant postoperative complications with a surgical reintervention rate of 32.5%. Overall, 21 patients (52%) reported recurrent constipation and of these 14 (65%) had recurrent RIMP; six patients were treated successfully by rubber-band ligation alone. Two patients (5%) experienced new onset faecal incontinence. The recurrence rate of RIMP was unaffected by the type of operation, being 53% after manual techniques and 48% after combined procedures. There was no difference between postoperative manometric values in patients presenting with recurrent RIMP or constipation compared with those without RIMP or constipation on follow-up. Forty-eight percent of the patients with both recurrent constipation plus RIMP had manometric evidence of non-relaxing puborectalis syndrome compared with 26% with RIMP but without constipation (P<0.05). Ten of the 14 patients (71%) with anxiety and/or depression complained of recurrent constipation after surgery compared with nine of the 26 patients (24%) with normal psychological profiles (P<0.01). Patients with a preoperative rectocele were more likely to suffer from recurrent constipation than those without rectocele (eight out of 15, 53.3% vs. seven out of 25, 28%; P<0.05).

CONCLUSIONS

Primary excision of RIMP does not seem an effective treatment for obstructed defecation with predictive factors for an adverse outcome in terms of recurrence (RIMP and constipation) including the presence of preoperative non-relaxing puborectalis syndrome and a demonstrated anxiety or depression psychological profile. The technique of prolapsectomy does not seem to affect outcome.

Stapled haemorrhoidopexy in fourth degree haemorrhoidal prolapse: is it worthwhile?

INTRODUCTION

Ten years after the introduction of stapled haemorrhoidopexy few studies have stratified patients by degree of haemorrhoidal disease when analysing results. Objective The aim of this study was prospectively to evaluate 116 patients who underwent stapled anopexy conducted by the same surgeon for III or IV degree haemorrhoidal prolapse.

MATERIALS AND METHODS

One hundred and sixteen consecutive patients affected by symptomatic haemorrhoids of III or IV degree underwent stapled anopexy using the technique described by Longo in the period January 2001 to October 2003. Mean follow-up was 28.1 months. Fischer's exact test was used for statistical analysis. Results, in terms of morbidity and recurrence rates, were stratified according to degree of haemorrhoidal disease.

RESULTS

There was no statistically significant difference between the results for third degree compared with fourth degree prolapse although there was a trend towards increased incidence of postoperative bleeding and recurrence.

CONCLUSION

Third degree haemorrhoidal prolapse remains the best indication for stapled haemorrhoidopexy. This procedure may also be indicated in fourth degree haemorrhoidal prolapse. Patients with fourth degree haemorrhoids may be subjected to this procedure following adequate discussion of the outcome.

Prospective randomised clinical trial of single versus double purse-string stapled mucosectomy in the treatment of prolapsed haemorrhoids

BACKGROUND AND AIMS

Despite the excellent results published on circular stapled mucosectomy (CSM), there is still some concern about the application of PPH-33 in the advanced haemorrhoidal disease, where a major prolapse may lead to insufficient resection and ensuing early recurrence. This study is aimed at comparing the outcomes after single purse-string CSM versus double purse-string CSM.

PATIENTS AND METHODS

A prospective randomised clinical trial of single versus double purse-string CSM for grade III-IV symptomatic haemorrhoids was used. One hundred consecutive patients were randomised to single (group 1, N=50) versus double purse-string CSM (group 2, N=50).

RESULTS

The mean age was 50.7 years, with a predominance of males (63 vs. 37). Haemorrhoids were classified as grade III in 59% and grade IV in 41% of the patients. Mean follow-up was 26 months. Demographic and clinical features showed no differences between the two groups. The size of the resected doughnut was greater in group 2 (4.95 vs. 3.55 cm; p<0.05), as was the distance of the suture from the dentate line (3.56 vs. 3.16 cm; p<0.05). Early postoperative pain was significantly less in group 2 (linear analogue scale from 0 to 10), 2.08 vs. 3.56 (p<0.001). Postoperative haemorrhage was absent or minimal in 79% of patients. Three patients from group 1 reported persistent pain that was resolved within the first few postoperative months. There were two recurrences in group 1.

CONCLUSION

Double purse-string CSM resects a greater doughnut, increases the distance of the staple suture from the dentate line and reduces early postoperative pain in comparison to single purse-string CSM. Larger series are necessary to assert whether recurrence is lower.

Stapled hemorrhoidopexy versus milligan-morgan hemorrhoidectomy: a prospective, randomized, multicenter trial with 2-year postoperative follow up

PURPOSE

The purpose of this study was to compare the outcome of stapled hemorrhoidopexy (SH group) performed using a circular stapler with that of the Milligan-Morgan technique (MM group). The goals of the study were to evaluate the efficacy and reproducibility of stapled hemorrhoidopexy and define its place among conventional techniques.

METHODS

A series of 134 patients were included at 7 hospital centers. They were randomized according to a single-masked design and stratified by center (with balancing every 4 patients). Patients were clinically evaluated preoperatively and at 6 weeks, 1 year, and a minimum of 2 years after treatment. Patients completed a questionnaire before and 1 year after surgery to evaluate symptoms, function, and overall satisfaction.

RESULTS

The mean follow-up period was 2.21 years +/- 0.26 (1.89-3.07). Nine patients (7%) could not be monitored at 1 or 2 years, but 4 of these 9 nevertheless filled in the 1-year questionnaire. The patients in the SH group experienced less postoperative pain/discomfort as scored by pain during bowel movement (P < 0.001), total analgesic requirement over the first 3 days (according to the World Health Organization [WHO] class II analgesics [P = 0.002]; class III [P = 0.066]), and per-patient consumption frequency of class III analgesics (P = 0.089). A clear difference in morphine requirement became evident after 24 hours (P = 0.010). Hospital stay was significantly shorter in the SH group (SH 2.2 +/- 1.2 [0; 5.0] versus MM 3.1 +/- 1.7 [1; 8.0] P < 0.001). At 1 year, no differences in the resolution of symptoms were observed between the 2 groups, and over 2 years, the overall incidence of complications was the same, specifically fecaloma (P = 0.003) in the MM group and external hemorrhoidal thrombosis (P = 0.006) in the SH group. Impaired sphincter function was observed at 1 year with no significant difference between the groups for urgency (12%), continence problems (10%), or tenesmus (3%). No patient needed a second procedure for recurrence within 2 years, although partial residual prolapse was detected in 4 SH patients (7.5%) versus 1 MM patient (1.8%) (P = 0.194).

CONCLUSION

Stapled hemorrhoidopexy causes significantly less postoperative pain. The technique is reproducible and can achieve comparable outcomes as those of the MM technique as long as the well-described steps of the technique are followed. Like with conventional surgery, anorectal dysfunction can occur after stapled hemorrhoidopexy in some patients. Its effectiveness in relieving symptoms is equivalent to conventional surgery, and the number of hemorrhoidal prolapse recurrences at 2 years is not significantly different. Hemorroidopexy is applicable for treating reducible hemorrhoidal prolapse.

Correlation of histology with anorectal function following stapled hemorrhoidectomy

INTRODUCTION

The inadvertent removal of smooth muscle during the use of stapled hemorrhoidectomy had raised concerns about its effects on postoperative anorectal function. We correlated the amount of smooth muscle removed with anorectal function in the early postoperative period.

METHODS

Patients were assessed preoperatively with an Eypasch quality-of-life questionnaire and underwent anorectal manometry and physiology testing. This was followed by a similar examination at three months postoperatively. Patients were operated on by a single surgeon and the excised anorectal mucosa was sent for histologic examination. The amount of smooth muscle excised was expressed semiquantitatively as a percentage of the total tissue removed.

RESULTS

Sixty-eight patients (33 males) were recruited prospectively, with median age of 44 years. Six patients were lost to follow-up. Removal of anal transitional zone did not increase the incidence of incontinence. Both median preoperative and postoperative continence scores were good. Only one patient had incontinence to gas as a result of the operation. Median preoperative and postoperative quality-of-life scores were 114 and 131, respectively, out of a total of 144, the higher postoperative scores showing an improvement. Correlation of quality-of-life scores and mean resting anal pressures with percentage of smooth muscle removed did not show any statistical significance.

CONCLUSIONS

Some smooth muscle will invariably be excised in stapled hemorrhoidectomy but the amount of smooth muscle removed did not significantly affect the continence score, quality of life, or mean anal resting pressure after stapled hemorrhoidectomy. It remains a safe and preferred procedure for the treatment of hemorrhoids.

Pathological audit of stapled haemorhoidopexy

INTRODUCTION

Stapled haemorrhoidopexy is increasingly used for the surgical management of prolapsing haemorrhoids. Accurate placement of the staple line is essential to avoid involvement of the internal anal sphincter (IAS) and the pain sensitive squamous epithelium. The aim of this study was to correlate histology with symptomatic outcome after stapled haemorrhoidopexy.

PATIENTS AND METHODS

A single pathologist reviewed one hundred and six consecutive rectal mucosal specimens. Each specimen was assessed for the presence of columnar, transitional and squamous epithelium as well as involvement of smooth and skeletal muscle. In November 2003 all patients were sent a previously validated postal questionnaire about haemorrhoidal symptoms and a Cleveland Clinic continence scale. Symptomatic outcome was compared between patients who did or did not have squamous epithelium involvement in their pathology specimens and were analysed by Mann-Whitney U-test.

RESULTS

One hundred and six stapled haemorrhoidopexies were performed between June 2001 and September 2003. Eighty-four patients (79%) returned the questionnaire; 19 patients had squamous epithelium present in the pathology specimens. There was no significant difference between symptom or Cleveland Clinic scores in patients with or without squamous epithelium in their pathology specimens. Some specimens (n = 6) were found to have smooth muscle underlying squamous epithelium; this was interpreted as the presence of internal anal sphincter (IAS) within the specimen. There was no significant difference in Cleveland Clinic scores between this group and those without IAS involvement.

CONCLUSION

This study has not demonstrated a long-term difference in symptomatic outcome or continence in patients who have squamous epithelium present in their stapled haemorrhoidopexy specimens.

Comparison of electrotherapy of hemorrhoids and Ferguson hemorrhoidectomy in a randomized prospective study

BACKGROUND

Ferguson hemorrhoidectomy has been shown to be associated with significant amount of post-operative (post op) pain and complications. However, electrotherapy in which hemorrhoidal tissue is not excised might not be associated with severe complications.

OBJECTIVE

Our aim was to compare the results of Ferguson hemorrhoidectomy with electrotherapy methods using 16 and 30 mA (milliampers) direct current (DC).

METHODS

Four hundred and eight patients with symptomatic hemorrhoids, grades 1, 2 and 3, were randomly assigned into 3 groups. Group A (136 patients) underwent Ferguson hemorrhoidectomy, group B1 (136 patients) and group B2 (136 patients) were subjected to electrotherapy using 16 and 30 mA, respectively. The groups were compared in terms of duration of procedures, duration of hospital stay, post op pain severity and post op complications including recurrence, infection and non-healing ulcers.

RESULTS

All patients in group A had severe pain for 7-14 days of post op. However, in group B1, 88(65%) patients had mild pain during the treatment and 1st post op day; 28(21%) of them could not tolerate the operation; 20(15%) of them had mild pain and 10(7.5%) of them had moderate pain up to day 7. In group B2, 47(35%) of patients had sever pain for 6 h and 20(15%) of them experienced mild pain for 2-7 days post op. The one day hospital stay in group A and group B2 were 82 and 97%, respectively, while patients in group B1 were treated as out patients. Mean procedure time for one hemorrhoidectomy in group A was 23 min, in electrotherapy using 16 and 30 mA was 9.7 and 6.1 min, respectively. The overall success rate with the first application in group B1 was 57% and in group B2 was 93%.

CONCLUSION

Electrotherapy method using 30 mA DC could significantly decrease post op pain, operation time and hospital stay. This method had good success rate and very low post op complications compared to Ferguson hemorrhoidectomy and using 16 mA method. Therefore, due to its effectiveness, less pain, rapidity and safeness, we recommend it.

Anal endosonography and its role in assessing the incontinent patient

Anal endosonography is now recognized as an important investigation in the assessment of faecal incontinence. The endosonographer needs to be aware that the anatomy of the anal sphincter is complex and therefore there can be pitfalls in the interpretation of images. The findings have clinical implications on subsequent management and can contribute to prognosticating outcome. However, anal endosonography has a complementary role and other investigations, such as anal manometry, should be performed before intervention.

Stapled hemorrhoidopexy: the argument for usage

Stapled hemorrhoidopexy is a new procedure for the treatment of symptomatic internal hemorrhoids. Experience and prospective trials are helping to define this procedure's role. Published data confirm that stapled hemorrhoidopexy offers similar control of symptoms with the benefits of reduced postoperative pain when compared with excisional techniques. Reduction in pain is the most significant benefit of this operation. Clearly, the cost of the stapling device exceeds the cost of the sutures required to perform an excisional hemorrhoidectomy. Patients should undergo medical therapy and rubber band ligation first; however, patients being considered for excisional hemorrhoidectomy should be offered stapled hemorrhoidectomy as a less painful alternative.

Can the procedure for prolapsing hemorrhoids (PPH) be done twice? Results of a porcine model

BACKGROUND

The procedure for prolapsing hemorrhoids (PPH) is a new surgical method for the treatment of symptomatic hemorrhoids. In cases of recurrent prolapse, the performance of a second PPH may result in a ring of mucosa and submucosa between the two circular staple lines. In this study, we used a porcine model to assess whether PPH can be safely performed twice.

METHODS

Five adult pigs underwent two PPH procedures in one session, leaving a ring of approximately 1 cm of mucosa between the two staple lines. One month later, the pigs were examined under anesthesia. The anal canal was assessed using the following four methods: (a) clinical examination, (b) evaluation of mucosal blood perfusion at different levels of the anal canal via a laser Doppler flow detector, (c) measurement of concentrations of hydroxyproline and collagen to check for fibrosis, and (d) histopathological examination.

RESULTS

At the completion of the study period, all five pigs showed no clinical evidence of anorectal dysfunction. On examination under anesthesia 1 month after surgery, there was no evidence of anal stenosis in any of the pigs. The mean mucosal blood flow between the two staple lines did not differ significantly from the flow measured proximally and distally (394 vs 363 and 339 flow units, respectively; p = NS). The collagen levels, based on hydroxyproline concentration, were 81 mcg/mg between the staple lines, compared to 82 and 79 proximally and distally, respectively ( p = NS). There was no significant difference in degree of fibrosis, as assessed histopathologically, between specimens taken from the ring between the staple lines and specimens taken from the area external to the staple lines.

CONCLUSIONS

The results of this porcine model suggest that a second synchronous PPH is feasible. A controlled experience involving human subjects is required to determine the safety and usefulness of this technique in cases of metachronous application for recurrent or residual hemorrhoids.

Ano-rectal physiological changes after rubber band ligation and closed haemorrhoidectomy

OBJECTIVE

The effect of treatment for haemorrhoids on ano-rectal physiology was studied in a prospective longitudinal follow-up study.

METHODS

Thirty-six consecutive patients having II-III degree (Group I, 18 patients) or IV degree (Group II, 18 patients) haemorrhoids were studied. Group I underwent rubber band ligation while Group II underwent closed scissors haemorrhoidectomy.

RESULTS

Patients in Group I had significantly lower maximum basal pressure (P < 0.05) and also significantly lower maximum squeeze pressure (P < 0.05) compared to Group II before treatment. Both basal and squeeze pressures dropped after haemorrhoidectomy (P < 0.001) whereas they remained unchanged after rubber band ligation (P > 0.1). The volume of first sensation was higher in Group II before treatment (P < 0.001) and remained so after treatment. Rectal compliance was higher (P < 0.005) in Group I before treatment. It increased significantly in both groups (P < 0.05, Group I; P < 0.001, Group II) after treatment.

CONCLUSIONS

The results show a significant increase in anal pressures in constantly prolapsing (IV degree) haemorrhoids. Most of the physiological differences observed between the two groups were abolished after treatment. This suggests that these may be a consequence rather than a cause of haemorrhoids.