The tissue-selecting technique: segmental stapled hemorrhoidopexy

Latest Research Trends on the Management of Hemorrhoids

Hemorrhoids manifest with a range of symptoms and severities, prompting the development of various conservative, interventional, and surgical treatments. Selecting the most suitable treatment for each case is challenging, especially with the continuous evolution of new methods. This review aims to advance hemorrhoid treatment and research by exploring recent developments over the last five years. Conservative approaches have focused on isolating active ingredients from traditional herbal remedies to create new products and understand their mechanisms. In office-based treatments, advanced devices such as modified rubber band ligation and polymer clips with stronger binding forces have been introduced. Polidocanol in foam form has shown promise in sclerotherapy, while infrared coagulation is being replaced by alternative energy-based methods. Additionally, endoscopic office treatments and embolization of hemorrhoidal vessels via angiography are increasingly used as safer options for patients with high surgical risks or bleeding issues. Stapled hemorrhoidopexy has shifted to partial resection instead of complete circular resection, and hemorrhoidal artery ligation techniques have been reported to be effective when combined with stapled hemorrhoidopexy or excisional hemorrhoidectomy in severe cases. Evidence is growing that hemorrhoidal artery ligation remains effective even without Doppler guidance. With ongoing research into various methods, there is a need for scientific comparison and evaluation of their advantages and disadvantages, standardization of indicators and treatment protocols, and cost-effectiveness considerations. Surgeons should offer well-informed options and explanations to patients, based on a comprehensive understanding of available treatments.

Comparison of the efficacy and safety of different surgical procedures for patients with hemorrhoids: a network meta-analysis

PURPOSE

This study used a network meta-analysis to evaluate the efficacy and safety of different surgical approaches in patients with hemorrhoids.

METHODS

PubMed, Embase, Web of science, and Cochrane Library were searched for randomized controlled trials on patients with hemorrhoids treated by different surgical procedures. The search was conducted until January 15, 2023. Two investigators independently screened the resulting literature, extracted information, evaluated the risk of bias of the included studies, and performed a network meta-analysis.

RESULT

A total of 23 randomized controlled studies were included and involved 3573 patients and 10 interventions, namely L (Ligasure), M-M (Milligan-Morgan), F (Ferguson), H (Harmonic), OH (open Harmonic), CH (closed Harmonic), PPH (procedure for prolapse and hemorrhoids), TST (tissue selecting technique), T-S (TST STARE+; tissue selection therapy stapled transanal rectal resection plus), and STARR (stapled transanal rectal resection). Network meta-analysis results showed that L has the shortest mean operating time and STARR has the longest mean operating time, F and H have the longest length of hospitalization and T-S has the shortest length of hospitalization, PPH has the most intraoperative blood loss and L has the least intraoperative blood loss, TST has the shortest time to first defecation and M-M has the longest time to first defecation, STARR had the least recurrence and PPH had the most recurrence, PPH had the least anal stenosis and L had the most anal stenosis, and F had the least postoperative pain after 24 h and PPH had the most postoperative pain after 24 h.

CONCLUSION

Current evidence suggests that L is best at reducing mean operative time and intraoperative bleeding, T-S is best at reducing mean length of stay, TST has the shortest time to first defecation, STARR is best at reducing recurrence rates, PPH is best at reducing postoperative anal stricture, and F is best at reducing postoperative pain after 24 h.

Outcomes of Modified Tissue Selection Therapy Stapler in the Treatment of Prolapsing Hemorrhoids

Objective

Tissue selection therapy staplers (TSTs) are widely used to treat prolapsing hemorrhoids; however, some disadvantages exist. We describe a modified technique for the treatment of prolapsing hemorrhoids, with the aim of minimizing the risk of anal stenosis and anal incontinence and reducing the impact of postoperative complications from the stapling technique. We applied a modified TST procedure, and the preliminary data were used to test the efficacy and safety of this new technique.

Methods

We conducted a retrospective study of patients who underwent modified TST for prolapsing hemorrhoids at our department between January 2018 and January 2020. All patients received a modified TST. Most prolapsing hemorrhoids were not segmentally resected and were instead selectively removed. The demographics, preoperative characteristics, postoperative complications, therapeutic effects, and patient satisfaction were collected and analyzed.

Results

A total of 106 patients were included in the study; 53 were men and 53 women (mean age, 49.24 years). The mean operative time was 55.01 min, and the mean hospital stay was 7.82 days. After surgery, three patients experienced bleeding (2.83%), 2 patients experienced anal discharge (1.89%), 2 patients experienced tenesmus (1.89%), and 5 patients experienced anal tags (4.72%). Anal incontinence, persistent post stapler pain, rectovaginal fistula and anal stenosis did not occur. Two patients developed recurrent symptomatic hemorrhoids (1.89%). The total effective rate of the surgery and the total satisfaction rate of the patients was 97.17%.

Conclusions

The modified tissue selection therapy stapler technique was a satisfactory and economical treatment for prolapsing hemorrhoids at a follow-up period of 1 year. The modified TST was associated with reduced anal stenosis and anal incontinence, less persistent post stapler pain and a minimal risk of rectovaginal fistula.

Modified Stapled Transanal Rectal Resection Procedure for Limited Rectal Prolapse: A Viable Alternative to the Delorme Operation

Purpose. The optimal surgical approach for full-thickness rectal prolapse (FTRP) remains controversial. In China, patients with limited FTRP (<5 cm in length) are usually managed by perineal surgery. We retrospectively assessed the outcome of Delorme's procedure and compared it with modified stapled transanal rectal resection (STARR). Methods. The study was conducted in 2 public tertiary referral centers in China with modified STARR or Delorme's procedure performed by experienced surgeons. Outcomes assessed recurrence, operative times, blood loss, complications, length of hospital stay, and continence and constipation scoring. Results. Between December 2012 and May 2019, 65 patients were assessed, including 48 with modified STARR (group 1) and 17 with Delorme's procedure (group 2). The median follow-up was 22 months (range, 3-86 months). The mean operative time for group 1 was 37.4 ± 17.5 minutes vs 74.3 ± 30.6 minutes for group 2 (P < .001). The blood loss for group 1 was significantly lower than that for group 2 (17.4 ± 15.9 mL vs 27.8 ± 16.7 mL, respectively; P = .028). There was no significant difference between groups in recurrence (group 1 18.8% vs group 2 23.5%; P = .944) with no effect of operation type. Both procedures showed improvement in constipation and continence scoring with a similar impact. Conclusions. Modified STARR and the Delorme operation are comparable in managing limited FTRP with superior results in operative time and blood loss for STARR.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

SETTINGS

The study was conducted at a single academic center.

PATIENTS

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

INTERVENTIONS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

A Modification of the Stapled TransAnal Rectal Resection (STARR) Procedure for Rectal Prolapse

PURPOSE

This study was designed to assess the safety, efficacy, and postoperative outcomes of the modified Stapled TransAnal Rectal Resection (modified STARR) in patients presenting with cases of limited external rectal prolapse.

METHODS

A prospective cohort of patients with mild rectal prolapse undergoing rectal resection with the Tissue-Selecting Technique Stapled TransAnal Rectal Resection Plus (TSTStarr Plus) stapler between February 2014 and September 2016 was reviewed retrospectively.

RESULTS

Twenty-five eligible patients underwent rectal resection with the TSTStarr Plus stapler. The median vertical height of the resected specimen was 5.0 cm (range = 3.1-10 cm) with all cases being confirmed histologically as full-thickness resections. Over a follow-up of 33.6 ± 9.4 months, only 1 case (4%) was encountered with recurrence. The mean postoperative Wexner score was significantly improved when compared with the preoperative scores (preoperative: median = 3, range = 0-20, vs postoperative: median = 2, range = 0-20, respectively; P = .010). The median preoperative Symptom Severity Score and Obstructed Defecation Score were both decreased compared with the postoperative scores ( P = .001).

CONCLUSIONS

Modified STARR in management of mild rectal prolapse appear to be a safe and effective technique. The initial results would encourage a more formal prospective assessment of this technique as part of a randomized trial for the management of mild rectal prolapse.

Treatment of Prolapsing Hemorrhoids in HIV-Infected Patients with Tissue-Selecting Technique

The aim of this retrospective study was to evaluate the outcome of a tissue-selecting therapy stapler (TST) for prolapsing hemorrhoids in HIV-infected patients. Sixty-two patients with stage III-IV hemorrhoidal prolapse were treated with TST by a single surgeon between June and November 2014. The TST group comprised 32 patients (4 females), and the TST + HIV group comprised 30 HIV-infected patients (3 females). Age, gender, and preoperative examination as well as intraoperative and postoperative features were assessed. There was no marked difference in hemorrhoidal prolapse between the TST and HIV + TST groups, except for patient satisfaction at 12 months. TST is an effective and safe technique for treatment of prolapsing hemorrhoids in HIV-infected patients.