Anal mucosectomy for haemorrhoids: should we start to speak Chinese?

Stapled Hemorrhoidopexy: "Mucosectomy or Not Only Mucosectomy, This Is the Problem"

Introduction: Stapled hemorrhoidopexy was originally defined as a rectal mucosectomy. The aims of our retrospective, single-center study were to demonstrate if the excised specimen comprises only the mucosa or more wall rectal layers and if the latter excision should be considered a technical mistake with an increase in complications.

Materials and Methods: We histopathologically analyzed surgical samples from patients who underwent stapled hemorrhoidopexy performed between 2014 and 2019. Patients were divided into three groups, according to the stapler used: Group A (single PPH®), Group B (double PPH®), and Group C (CPH34 HV™). We evaluated the actual wall layers included in the stapled rectal ring. For every specimen, we reconstructed the history of the corresponding patient and the incidence of complications.

Results: Of the 137 histological slides available, 13 were only mucosectomies (9.5%), and 124 presented also the submucosa and muscularis propria (90.5%)−50/58 patients in Group A, 28/28 in Group B, and 46/51 in Group C. No statistically significant difference in the rate of complications was found when stratifying patients according to the thickness of the resection [mucosectomy (M) or “full thickness” (FT)].

Discussion: Stapled hemorrhoidopexy is not a simple mucosectomy but a resection of the rectal wall with almost all its layers. This concept defines the entity of the surgical procedure and excludes a direct correlation with an increased rate of complications.

Does a more extensive mucosal excision prevent haemorrhoidal recurrence after stapled haemorrhoidopexy? Long-term outcome of a randomized controlled trial

AIM

The study aimed in a multicentric randomized controlled trial to define the role of a more extensive mucosal resection on recurrence of mucosal prolapse in patients with Stage III haemorrhoids undergoing stapled haemorrhoidopexy.

METHOD

In all, 135 patients were randomized to treatment with a PPH-01/03 (Ethicon EndoSurgery) or an EEA (Covidien) stapler. They were reviewed after a minimum follow-up of 4 years to determine the rate of recurrent mucosal prolapse and general condition (wellness evaluation score). Postoperative bowel dysfunction was assessed using the Rome III criteria.

RESULTS

Eighty-seven (65%) of the 135 patients (48 in the EEA stapler group and 37 in the PPH group) were available for long-term follow-up. The two groups were comparable for age, gender and duration of follow-up (mean 49.3 ± 5.4 months and 49.0 ± 5.3 months respectively). In the EEA group, 11 (23%) patients had some degree of recurrent prolapse compared with 12 (32%) in the PPH group (P = 0.409). Persistence of anal bleeding was significantly higher in the PPH group (P = 0.04) while the postoperative Haemorrhoid Symptom Score was significantly better in the EEA group (1.73 ± 1.65 vs 3.17 ± 1.94, P < 0.001). The wellness evaluation score was significantly better in the EEA group (1.2 ± 1.27 vs 0.6 ± 1.0, P = 0.028). Furthermore, 7 (15%) of the patients in the EEA group complained of some evacuation disturbance compared with 13 (36%) in the PPH group (P = 0.021).

CONCLUSION

The study failed to demonstrate any significant difference in the long-term recurrence rate of Stage III haemorrhoids using EEA or PPH. Nevertheless, use of the larger volume EEA provides better symptom resolution compared with PPH.

Early complications after stapled hemorrhoidopexy: a retrospective study comparing three different circular staplers

BACKGROUND

A retrospective analysis was performed to assess differences between three devices used for stapled hemorrhoidopexy (SH) in terms of early complications and complaints and the volume of excised tissue.

MATERIALS AND METHODS

All patients who underwent an elective SH from January 2008 to December 2014 were included. Three different devices were used: the PPH03 stapler (Ethicon EndoSurgery, Diegem, Belgium) and the Chex^TM CPH32 and CPH34 staplers (Frankenman International Ltd, Hong Kong, China). The demographic data were reviewed as well as indications for surgery. The volume of the excised tissue was determined by reviewing the anatomopathologic reports. We assessed early postoperative complications and complaints and compared the rate of complications between the three used devices.

RESULTS

From 1 January 2008 to 30 December 2014, 253 patients underwent a SH using three different devices. One hundred and seventy-four patients were treated with the PPH03 stapler, 51 with the Chex^TM CPH32 stapler and 28 with the Chex^TM CPH34 stapler. Postoperatively, 28.5% of patients experienced minor early complications. There was no difference in complication rates between the three different devices, except for the occurrence of postoperative stenosis with more stricture formation when using the CPH32 stapler (p < 0.0001). The volume of tissue excised by the Chex^TM CPH32 and CPH34 staplers was significantly larger than in the PPH03 group (18.19 ± 9.67 mL; 25.53 ± 13.99 mL; 11.63 ± 5.66 mL; p < 0.0001).

CONCLUSIONS

Postoperative anal stenosis was more common after circular stapled hemorrhoidopexy with the ChexTM CPH32 stapler.

Tailored prolapse surgery for the treatment of haemorrhoids and obstructed defecation syndrome with a new dedicated device: TST STARR Plus

OBJECTIVE

The aim of the study was to assess the safety, efficacy and feasibility of stapled transanal procedures performed by a new dedicated device, TST STARR Plus, for tailored transanal stapled surgery.

METHODS

All the consecutive patients admitted to eight referral centres affected by prolapses with III-IV degrees haemorrhoids or obstructed defecation syndrome (ODS) with rectocele and/or rectal intussusception that underwent stapled transanal resection with TST STARR plus were included in the present study. Haemostatic stitches for bleeding of the suture line, specimen volume, operative time, hospital stay and perioperative complications were recorded.

RESULTS

From 1 November 2012 to 31 March 2013, 160 consecutive patients (96 females) were enrolled in the study. In 94 patients, the prolapse was over the half of the circular anal dilator (CAD). The mean duration of the procedure was 25 min. The mean resected volume of the specimen was 13.3 cm(3), the mean hospital stay was 2.2 days. In 88 patients (55%), additional stitches on the suture line were needed (mean 2.1). Suture line dehiscence was reported in four cases, with intraoperative reinforcement. Bleeding was reported in seven patients (5%). Urgency after 30 days was reported in one patient. No major complication occurred.

CONCLUSIONS

The new device seems to be safe and effective for a tailored approach to anorectal prolapse due to haemorrhoids or obstructed defecation.