Modified procedure for prolapse and hemorrhoids: Lower recurrence, higher satisfaction

BACKGROUND

Hemorrhoidal prolapse is a common benign disease with a high incidence. The treatment procedure for prolapse and hemorrhoids (PPH) remains an operative method used for internal hemorrhoid prolapse. Although it is related to less pos-operative pain, faster recovery and shorter hospital stays, the postoperative recurrence rate is higher than that of the Milligan-Morgan hemorrhoidectomy (MMH). We have considered that recurrence could be due to shortage of the pulling-up effect. This issue may be overcome by using lower purse-string sutures [modified-PPH (M-PPH)].

AIM

To compare the therapeutic effects and the patients’ satisfaction after M-PPH, PPH and MMH.

METHODS

This retrospective cohort study included 1163 patients (M-PPH, 461; original PPH, 321; MMH, 381) with severe hemorrhoids (stage III/IV) who were admitted to The 2^nd Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University from 2012 to 2014. Early postoperative complications, efficacy, postoperative anal dysfunction and patient satisfaction were compared among the three groups. Established criteria were used to assess short- and long-term postoperative complications. A visual analog scale was used to evaluate postoperative pain. Follow-up was conducted 5 years postoperatively.

RESULT

Length of hospital stay and operating time were significantly longer in the MMH group (8.05 ± 2.50 d, 19.98 ± 4.21 min; P < 0.0001) than in other groups. The incidence of postoperative anastomotic bleeding was significantly lower after M-PPH than after PPH or MMH (1.9%, 5.1% and 3.7%; n = 9, 16 and 14; respectively). There was a significantly higher rate of sensation of rectal tenesmus after M-PPH than after MMH or PPH (15%, 8% and 10%; n = 69, 30 and 32; respectively). There was a significantly lower rate of recurrence after M-PPH than after PPH (8.7% and 18.8%, n = 40 and 61; P < 0.0001). The incidence of postoperative anal incontinence differed significantly only between the MMH and M-PPH groups (1.3% and 4.3%, n = 5 and 20; P = 0.04). Patient satisfaction was significantly greater after M-PPH than after other surgeries.

CONCLUSION

M-PPH has many advantages for severe hemorrhoids (Goligher stage III/IV), with a low rate of anastomotic bleeding and recurrence and a very high rate of patient satisfaction.

M-PPH

Clinical efficacy of integral theory–guided laparoscopic integral pelvic floor/ligament repair in the treatment of internal rectal prolapse in females

BACKGROUND

Internal rectal prolapse (IRP) is one of the most common causes of obstructive constipation. The incidence of IRP in women is approximately three times that in men. IRP is mainly treated by surgery, which can be divided into two categories: Abdominal procedures and perineal procedures. This study offers a better procedure for the treatment of IRP.

AIM

To compare the clinical efficacy of laparoscopic integral pelvic floor/ligament repair (IPFLR) combined with a procedure for prolapse and hemorrhoids (PPH) and the laparoscopic IPFLR alone in the treatment of IRP in women.

METHODS

This study collected the clinical data of 130 female patients with IRP who underwent surgery from January 2012 to October 2014. The patients were divided into groups A and B. Group A had 63 patients who underwent laparoscopic IPFLR alone, and group B had 67 patients who underwent the laparoscopic IPFLR combined with PPH. The degree of internal rectal prolapse (DIRP), Wexner constipation scale (WCS) score, Wexner incontinence scale (WIS) score, and Gastrointestinal Quality of Life Index (GIQLI) score were compared between groups and within groups before surgery and 6 mo and 2 years after surgery.

RESULTS

All laparoscopic surgeries were successful. The general information, number of bowel movements before surgery, DIRP, GIQLI score, WIS score, and WCS score before surgery were not significantly different between the two groups (all P > 0.05). The WCS score, WIS score, GIQLI score, and DIRP in each group 6 mo, and 2 years after surgery were significantly better than before surgery (P < 0.001). In group A, the DIRP and WCS score gradually improved from 6 mo to 2 years after surgery (P < 0.001), and the GIQLI score progressively improved from 6 mo to 2 years after surgery (P < 0.05). In group B, the DIRP, WCS score and WIS score significantly improved from 6 mo to 2 years after surgery (P < 0.05), and the GIQLI score 2 years after surgery was significantly higher than that 6 mo after surgery (P < 0.05). The WCS score, WIS score, GIQLI score, and DIRP of group B were significantly better than those of group A 6 mo and 2 years after surgery (all P < 0.001, Bonferroni) except DIRP at 2 years after surgery. There was a significant difference in the recurrence rate of IRP between the two groups 6 mo after surgery (P = 0.011). There was no significant difference in postoperative grade I-III complications between the two groups (P = 0.822).

CONCLUSION

Integral theory–guided laparoscopic IPFLR combined with PPH has a higher cure rate and a better clinical efficacy than laparoscopic IPFLR alone.

[Procedure for prolapse and hemorrhoids versus stapled transanal rectal resection in the treatment of grade IV hemorrhoids]

Objective: To compare the efficacy and safety of two procedures in the treatment of hemorrhoid: the procedure for prolapse and hemorrhoids (PPH) and stapled transanal rectal resection (STARR). Methods: A retrospective cohort research was conducted. Clinical data of 263 patients undergoing the first elective surgery for grade IV hemorrhoids by the same team of surgeons at our department from January 2015 to December 2016 were analyzed retrospectively, while those had other anorectal diseases, emergency surgery, inflammatory bowel disease, tumor and incomplete clinical data were excluded. PPH was performed in 129 patients and STARR was performed in 134 patients. PPH procedure: a circular purse 2-0 string suture was made at 4 cm above the dentate line; in accordance with the standard protocol, the PPH circular stapling devicewas introduced; the suture was closed, and a pull-through followed; the traction was continued; the stapler was fired; the prolapsed mucosa and submucosa were removed. STARR procedure: 3-5 needles were sutured in the anterior rectal mucosa, protecting the posterior wall mucosa; with the help of a finger the PPH stapler was inserted into the vaginal lumen; the sutures were hooked from both sides of the stapler to maintain traction; according to the disease condition, the suturewas tightened appropriately; stapler was screwed and activated; the anterior wall mucosa was removed; the joint of the both ends of anastomosis was cut; the posterior wall mucosa was removed as well. The short-term efficacy, surgical safety and prognosis of the two groups were compared. Results: There were 67 males (51.9%) in the PPH group and 57 (42.5%) males in the STARR group. The median age of the two groups was 51.0 (22.0, 80.0) years and 49.0 (24.0, 74.0) years, respectively. There were no significant differences in the baseline data between the two groups (all P>0.05). No significant differences in the intraoperative bleeding, length of hospital stay, postoperative analgesic drug use, postoperative bleeding, postoperative infection, etc. were found between two groups (all P>0.05). As compared to PPH group, STAAR group had longer operation time and higher hospitalization cost with significant differences [(44.0±19.3) minutes vs. (26.3±8.5) minutes, t=9.701, P=0.001; (11 047±473) yuan vs. (7674±309) yuan, t=32.826, P=0.001]. One case in STAAR group developed rectovaginal fistula. The median follow-up period of the whole group was 40 (33, 52) months. A total of 108 cases in STARR group and 114 cases in PPH group completed the follow-up. The 3-year disease-relapse rate was 0 in STARR group and 4.2% in PPH group (P=0.042). Conclusion: STARR procedure can improve the prognosis in the treatment of grade IV hemorrhoid, but attention should be paid to the development of complications.

Efficacy of procedure for prolapse and hemorrhoids vs traditional surgery for treatment of constipation caused by internal rectal prolapse with mixed hemorrhoids

AIM: To compare the clinical curative effect of procedure for prolapse and hemorrhoids (PPH) vs traditional surgery in the treatment of outlet obstructive constipation caused by internal rectal prolapse with mixed hemorrhoids.

METHODS: One hundred and twenty patients with internal rectal prolapse with mixed hemorrhoids treated from January 2010 to December 2012 were randomly divided into either a study group to receive PPH or a control group to receive traditional surgery (Milligan-Morgan hemorrhoidectomy + rectal mucosa ligation). Anorectal pressure was measured preoperatively and postoperatively and compared between the two groups. The quality of life was evaluated using the Patient Assessment of Constipation Quality of Life (PAC-QOL).

RESULTS: Anorectal pressure showed varying degrees of decrease in the two groups after operation; the decrease was not significant in the study group (P > 0.05), but was significant in the control group (P < 0.05). Except resting rectal pressure, other parameters showed significant differences between the two groups after operation (P < 0.05). The overall score and the score of each dimension of the PAC-QOL were statistically significant between the PPH and traditional operation groups, favoring the PPH group.

CONCLUSION: PPH is superior to traditional surgery with regards to curative effect and improvement of quality of life in the treatment of constipation caused by internal rectal prolapse with mixed hemorrhoids with regards to curative effect and improvement of quality of life.

Correlation between short-term anal control function and number of pacinian corpuscles in patients undergoing procedure for prolapse and hemorrhoids or Milligan-Morgan hemorrhoidectomy

AIM: To analyze the relevance between pathological damage and clinical complications of Milligan-Morgan hemorrhoidectomy and procedure for prolapse and hemorrhoids (PPH).

METHODS: Clinical data for 90 patients who were operated at Suzhou Hospital of Traditional Chinese Medicine, the Third Affiliated Hospital of He'nan College of Traditional Chinese Medicine and Affiliated Hospital of Nanjing University of TCM from June 2013 to June 2014 were retrospectively. The patients were divided into two groups, patients undergoing Milligan-Morgan hemorrhoidectomy and those undergoing PPH. Anal control function was assessed in both groups. All of surgical specimens underwent Alcian blue staining to count the number of pacinian corpuscles. Then the relevance between the pathological damage and clinical complications was analyzed.

RESULTS: The short-term anal control function had no statistically significant difference between the two groups. The number of pacinian corpuscles in resected tissue differed significantly between the PPH and Milligan-Morgan groups (P < 0.05). Compared with the Milligan-Morgan group, the number of pacinian corpuscles significantly increased in the PPH group (11.3 ± 6.11 vs 42.7 ± 9.86, P < 0.05). There was a positive correlation between anal control function and the number of Pacinian corpuscles.

CONCLUSION: The short-term anal control function had a significant difference between patients undergoing PPH and those undergoing traditional hemorrhoid surgery. The number of pacinian corpuscles was significantly higher in the PPH group than in the traditional hemorrhoid surgery group, which may be the reason why the short-term anal control function in the PPH group was inferior to that of the traditional hemorrhoid surgery group.

Procedure for prolapse and hemorrhoids vs traditional surgery for outlet obstructive constipation

AIM: To compare the clinical efficacies of two surgical procedures for hemorrhoid rectal prolapse with outlet obstruction-induced constipation.

METHODS: One hundred eight inpatients who underwent surgery for outlet obstructive constipation caused by internal rectal prolapse and circumferential hemorrhoids at the First Affiliated Hospital of Xinjiang Medical University from June 2012 to June 2013 were prospectively included in the study. The patients with rectal prolapse hemorrhoids with outlet obstruction-induced constipation were randomly divided into two groups to undergo either a procedure for prolapse and hemorrhoids (PPH) (n = 54) or conventional surgery (n = 54; control group). Short-term (operative time, postoperative hospital stay, postoperative urinary retention, postoperative perianal edema, and postoperative pain) and long-term (postoperative anal stenosis, postoperative sensory anal incontinence, postoperative recurrence, and postoperative difficulty in defecation) clinical effects were compared between the two groups. The short- and long-term efficacies of the two procedures were determined.

RESULTS: In terms of short-term clinical effects, operative time and postoperative hospital stay were significantly shorter in the PPH group than in the control group (24.36 ± 5.16 min vs 44.27 ± 6.57 min, 2.1 ± 1.4 d vs 3.6 ± 2.3 d, both P < 0.01). The incidence of postoperative urinary retention was higher in the PPH group than in the control group, but the difference was not statistically significant (48.15% vs 37.04%). The incidence of perianal edema was significantly lower in the PPH group (11.11% vs 42.60%, P < 0.05). The visual analogue scale scores at 24 h after surgery, first defecation, and one week after surgery were significantly lower in the PPH group (2.9 ± 0.9 vs 8.3 ± 1.1, 2.0 ± 0.5 vs 6.5 ± 0.8, and 1.7 ± 0.5 vs 5.0 ± 0.7, respectively, all P < 0.01). With regard to long-term clinical effects, the incidence of anal stenosis was lower in the PPH group than in the control group, but the difference was not significant (1.85% vs 5.56%). The incidence of sensory anal incontinence was significantly lower in the PPH group (3.70% vs 12.96%, P < 0.05). The incidences of recurrent internal rectal prolapse and difficulty in defecation were lower in the PPH group than in the control group, but the differences were not significant (11.11% vs 16.67% and 12.96% vs 24.07%, respectively).

CONCLUSION: PPH is superior to the traditional surgery in the management of outlet obstructive constipation caused by internal rectal prolapse with circumferential hemorrhoids.

Clinical application of procedure for prolapse and hemorrhoids

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

Procedure for prolapse and hemorrhoids for grade III and IV internal hemorrhoids: A systematic review

Procedure for prolapse and hemorrhoids (PPH) is a new surgical technique that was developed based on the modern concept of internal hemorrhoids. It has gained wide acceptance as the treatment of choice for grade III and IV internal hemorrhoids, because of less postoperative pain and faster return to normal activities. Here we perform a systematic review on the recent advances in PPH for grade III and IV internal hemorrhoids.