Complications and reoperations in stapled anopexy: learning by doing

Effects of Stapled Hemorrhoidopexy on Anorectal Function: A Prospective Randomized Controlled Trial

BACKGROUND

Stapled hemorrhoidopexy is a safe and acceptable alternative to traditional hemorrhoidectomy with shorter hospital stay, better satisfaction, and less postoperative pain. There have, however, been reports on early and late complications. Therefore, the present study was designed to assess the impact of stapled hemorrhoidopexy on anorectal function and continence.

METHODS

Sixty-one patients with rectal prolapse and/or symptomatic circumferential hemorrhoidal disease, as validated by the Wexner incontinence score, were included. Anal manometric indices were measured. The Wexner scores and anal manometric measures were compared pre- and postoperatively using the Mann-Whitney U test. (A P<0.05 was considered significant.).

RESULTS

Mean age was 46.8 years (range=18-80 y), with a mean follow-up time of 3 months. Fifty-one patients completed their follow-ups. For 45 patients with a Wexner score of 0 and no history of incontinence, the anal maximum squeezing pressure (AMD) was 125.3±43.1 mm Hg, the anal resting pressure (ARD) was 27.8±12.8 mm Hg, and the mean pressure was 40.0±16.8 mm Hg. The changes in the anorectal manometric indices before and 3 months after the operation were not statistically significant (P=0.99, P=0.55, and P=0.32, respectively). In 6 patients with Wexner scores of 1 or higher, the mean values of the AMD, ARD, and mean pressure not only decreased but also increased postoperatively, but the changes were not statistically significant (P=0.32, P=0.42, and P=0.45, correspondingly).

CONCLUSION

These data represent a series of patients with 3 months' follow-up after stapled hemorrhoidopexy and suggest that this technique is safe in experienced hands. It may have protective effects on anorectal function in patients with imperfect continent scores. Trial Registration Number: IRCT2015101324504N1.

Rectal inclusion cyst as a complication of stapled hemorrhoidopexy: A case report

RATIONALE

Stapled hemorrhoidopexy is gaining popularity for prolapsing hemorrhoids. However, like any other operation, there is always the potential risk of complications. Rectal inclusion cysts are rare complications that results from the potential space in the staple line.

PATIENT CONCERNS

A 49-year-old woman was admitted to our hospital with a complaint of anorectal pain and fever complaints after stapled hemorrhoidopexy. The endoanal ultrasonography showed unclear fluid containing a cystic lesion circuit to the rectum at the staple line.

DIAGNOSES

The endoanal ultrasonography strongly indicates the rectal inclusion cysts.

INTERVENTIONS AND OUTCOMES

A full thickness excision of the cyst was carried out along the staple line. The patient had complete recovery, with no recurrence or complaints for at least 6 months after the surgery.

LESSONS

Endosonography has an important role in investigating symptomatic patients after stapled hemorrhoidopexy. Once an inclusion cyst is diagnosed, excision of the stapled line is the only choice of treatment.

[Intraoperative pitfalls and complications in defecation disorders and rectal prolapse]

BACKGROUND

No generally accepted gold standard exists for the operative therapy of rectal prolapse in its variety of manifestations. Existing evidence suggests that an individualized choice of procedure provides the best result for each single patient. Knowledge of possible pitfalls and intraoperative management of complications in frequently applied procedures are important prerequisites for reliable treatment of affected patients.

MATERIAL AND METHODS

A consecutive series of 233 patients (June 2011-May 2016) with individualized choice of operative procedure in patients with rectal prolapse and rectocele based on an algorithm for a clinical treatment pathway and stapled hemorrhoidopexy were included. Intraoperative pitfalls and complications and their management (iPCM) were prospectively documented and analyzed.

RESULTS

The iPCM could be classified into three different categories: group I: iPCM was immediately noted and intraoperatively treated with no impact on the further clinical course (n = 20), group II: iPCM was successfully treated conservatively within a short time after the procedure (n = 9) and group III: iPCM required surgical revision (n = 5).

CONCLUSION

Individualized treatment of rectal prolapse and rectocele requires a broad spectrum of methods in specialized coloproctology units. A clinical treatment pathway facilitates the optimal choice of procedure. Overall the complication rates during surgical treatment of transanal rectal prolapse are low; however, available operative procedures hold specific risks and knowledge of these risks helps to avoid them. Once complications occur, measures demonstrated in this study lead to normal clinical courses in the majority of cases.

Documented complications of staple hemorrhoidopexy: a systematic review

A systematic review addressing reported complications of stapled hemorrhoidopexy was conducted. Articles were identified via searching OVID and MEDLINE between July 2011 and October 2013. Limitations were placed on the search criteria with articles published from 1998 to 2013 being included in this review. No language restrictions were placed on the search, however foreign language articles were not translated. Two reviewers independently screened the abstracts for relevance and their suitability for inclusion. Data extraction was conducted by both reviewers and entered and analyzed in Microsoft Excel. The search identified 784 articles and 78 of these were suitable for inclusion in the review. A total of 14,232 patients underwent a stapled hemorrhoidopexy in this review. Overall complication rates of stapled hemorrhoidopexy ranged from 3.3%-81% with 5 mortalities documented. Early and late complications were defined individually with overall data suggesting that early complications ranged from 2.3%-58.9% and late complications ranged from 2.5%-80%. Complications unique to the procedure were identified and rates recorded. Both early and late complications unique to stapled hemorrhoidopexy were identified and assessed.

Circular mucosal anopexy: Experience and technical considerations

INTRODUCTION

Circular mucosal anopexy (CMA) achieves a more comfortable postoperative period than resective techniques. But complications and recurrences are not infrequent. This study aims to evaluate of the efficacy of CMA in the treatment of hemorrhoids and rectal mucosal prolapse (RMP).

METHOD

From 1999 to 2011, 613 patients underwent surgery for either hemorrhoids or RMP in our hospital. CMA was performed in 327 patients. Gender distribution was 196 male and 131 female. Hemorrhoidal grades were distributed as follows: 28 patients had RMP, 46 2nd grade, 146 3rd grade and 107 4th grade. Major ambulatory surgery (MAS) was performed in 79.9%. Recurrence of hemorrhoids was studied and groups of recurrence and no-recurrence were compared. Postoperative pain was evaluated by Visual Analogical Scale (VAS) as well as early complications.

RESULTS

A total of 31 patients needed reoperation (5 RMP, 2 with 2nd grade, 17 with 3rd grade,/with 4th grade). No statistically significant differences were found between the non-recurrent group and the recurrent group with regards to gender, surgical time or hemorrhoidal grade, but there were differences related to age. In the VAS, 81.3% of patients expressed a postoperative pain ≤ 2 at the first week. Five patients needed reoperation for early postoperative bleeding. Six patients needed admission for postoperative pain.

CONCLUSIONS

Recurrence rate is higher in CMA than in resective techniques. CMA is a useful technique for the treatment of hemorrhoids in MAS. Pain and the rate of complications are both low.

Stapled hemorrhoidopexy: functional results, recurrence rate, and prognostic factors in a single center analysis

PURPOSE

Since its introduction, stapled hemorrhoidopexy (SHP), the so-called Longo procedure, became a widely accepted treatment option for prolapsing hemorrhoids. Nevertheless, from the early years, concerns grew about the early functional results and potential recurrences. In order to evaluate of SHP with special respect to early defecation disorders und recurrences, our single institute high-volume results were evaluated.

METHOD

One thousand one hundred forty-four consecutive patients with SHP for prolapsing hemorrhoids were evaluated in a period from January 2007 to December 2013. In a prospective analysis, patients were followed with special respect to postoperative complications, functional disorders, mainly perianal irritation, stenosis, and recurrence.

RESULTS

During the timeframe, a total of 663 men and 481 women were treated for prolapsing hemorrhoids. The mean age was 52.6 years (±14.4 years). Indication for surgery was prolapsing hemorrhoids in all cases. In addition to prolapse, 90 patients (7.9 %) suffered from bleeding, 96 patients (8.4 %) had itching, and 95 (8.3 %) had anal wetness; the mean operative time was 11 min (±4 min). Patients were treated as inpatients; the mean hospital stay was 3 days (±1 day). Early complications were observed in 14 patients (1.2 %). The follow-up revealed inflammatory reaction at the stapleline in 8 patients (0.7 %) and rectal stenosis in 22 cases (1.9 %), and recurrence was observed in 46 cases (4.0 %).

CONCLUSION

The data presented here provide evidence that SHP is a save procedure with a very low rate for functional disorders and low recurrence rate. Therefore, in our hands, SHP remains standard for prolapsing hemorrhoids.

Stapled anopexy and STARR in surgical treatment of haemorrhoidal disease

The treatment of hemorrhoidal disease using stapled anopexy (SA) is still burdened by a high incidence of recurrence. Probably this condition is secondary to inadequate removal of the prolapsed tissue due to the reduced capacity of resection from the adopted device. In order to limit the incidence of failures by providing a removal of a greater amount of prolapsed tissue was considered the opportunity to use the STARR technique even in the presence of haemorrhoidal disease not burdened by symptoms of obstructed defecation. We evaluated the early and at a distance results of 285 patients who had undergone in 2007-2011 surgical resection with trans-anal circular stapler for symptomatic III-IV degree haemorrhoids without obstructed defecation disorders. 237 patients were subjected to SA, while in the remaining 48, since on intervention prolapse committed the CAD more than half of the device, we performed a STARR. adopted the Chi square test (C) considering significant p-values less than 0.05. The anamnestic preoperative evaluation allowed to put the correct indication for surgical treatment in 80% of patients. Mean operative times, hospital stay, incidence of early and more important complications, the symptomatic recurrence of disease (5%) were not dissimilar in the two groups under consideration. Conversely (p < 0.05) the relief of residual asymptomatic disease (24 vs. 10%) was significant . The overall satisfaction was significantly higher in the ST group (73.5 vs 58.6%). The STARR in case of massive prolapse who express themselves with only haemorrhoidal disease is a safe technique, able to optimize the long-term effectiveness of trans-anal resection surgery, limiting the incidence of symptomatic recurrences. The information offered to the patient at the time of the consent to surgery must be extensive and detailed, always considering the possibility of adopting the two techniques alternately and that, at completion of the intervention, could be necessary also the removal of persistent skin tags.

Double PPH technique for hemorrhoidal prolapse: a multicentric, prospective, and nonrandomized trial

INTRODUCTION

Longo's technique (or PPH technique) is well known worldwide. Meta-analysis suggests that the failure due to persistence or recurrence is close to 7.7%. One of the reasons for the recurrence is the treatment of the advanced hemorrhoidal prolapse with a single stapling device, which is not enough to resect the appropriate amount of prolapse.

MATERIALS AND METHODS

We describe the application of "Double PPH Technique" (D-PPH) to treat large hemorrhoidal prolapses. We performed a multicentric, prospective, and nonrandomized trial from July 2008 to July 2009, wherein 2 groups of patients with prolapse and hemorrhoids were treated with a single PPH or a D-PPH. Results were compared. The primary outcome was evaluation of safety and efficacy of the D-PPH procedure in selected patients with large hemorrhoidal prolapse.

RESULTS

In all, 281 consecutive patients suffering from hemorrhoidal prolapse underwent surgery, of whom 74 were assigned intraoperatively to D-PPH, whereas 207 underwent single PPH. Postoperative complications were 5% in both groups (P = .32), in particular: postoperative major bleeding 3.0% in PPH versus 4.1% D-PPH (P = .59); pain 37.9 % PPH versus 27.3% D-PPH (mean visual analog scale [VAS] = 2.5 vs 2.9, respectively; P = .72); and fecal urgency 2.1% PPH versus 5.7% D-PPH (P = .8). Persistence of hemorrhoidal prolapse at 12-month follow-up was 3.7% in the PPH group versus 5.9% in the D-PPH group (P = .5).

CONCLUSIONS

Our data support the hypothesis that an accurate intraoperative patient selection for single (PPH) or double (D-PPH) stapled technique will lower in a significant way the incidence of recurrence after Longo's procedure for hemorrhoidal prolapse.

The Use of Bioabsorbable Staple-Line Reinforcement Performing Stapled Hemorrhoidopexy to Decrease the Risk of Postoperative Bleeding

Postoperative staple-line bleeding after stapled hemorrhoidopexy represents a major issue of this procedure, especially in the day surgery setting. In this study we assess the possible benefit of using circular bioabsorbable staple-line reinforcement to reduce the risk of hemorrhage when performing stapled hemorrhoidopexy in a day surgery setting. Patients with symptomatic II to III grade hemorrhoidal disease were randomly assigned into two groups. In Group A we performed a stapled hemorrhoidopexy using PPH33-03® with Seamguard®, a bioabsorbable staple-line reinforcement; in Group B, we used only a PPH33-03® stapler. We evaluated the intraoperative and postoperative staple-line bleeding and, secondarily, the duration of surgery, need for additional hemostatic stitches, and presence of postoperative complications. One hundred patients were enrolled in the study. Group A patients showed a statistically significant decrease of intraoperative bleeding (4 vs 42% in Group B) and hemostatic stitch placement (5.7 vs 42%) with the consequent reduction in mean operative time, postoperative pain, and tenesmus. There were no differences between the two groups in hemorrhoidal disease control or postoperative late complications. The use of bioabsorbable staple-line reinforcement while performing stapled hemorrhoidopexy may allow improvement of the safety of this procedure, especially in a day surgery setting.

Double stapled haemorrhoidopexy for haemorrhoidal prolapse: indications, feasibility and safety

AIM

Selected patients with haemorrhoidal prolapse undergoing double stapled anopexy with the procedure for prolapse and haemorrhoids (PPH03) were studied.

METHOD

Between March 2007 and March 2010, 235 patients referred with haemorrhoids were included in the study. Patients with obstructed defaecation were excluded. At surgery intraoperative evaluation for double stapled anopexy was carried out based on the criteria of prolapse occupying half or more of the anal circumference and redundant prolapsed tissue determined by the circular anal dilator. Patients fulfilling these criteria were submitted for double stapled anopexy with the PPH03 stapler. All clinical and operative data were recorded in a prospectively maintained database.

RESULTS

Among the 142 patients with haemorrhoidal prolapse having surgery 91 had a single and 51 a double stapled technique. The mean operative time was 34.8 min with no major or minor intraoperative complications. Recurrence at 48 months was 1.9% and the mean satisfaction score was 8.9.

CONCLUSION

The double stapled PPH03 technique in selected cases was as safe and effective as a single stapling technique with a lower incidence of recurrence over a medium-term follow-up.

Rectal perforation with life-threatening peritonitis following stapled haemorrhoidopexy

BACKGROUND

Stapled haemorrhoidopexy is a well recognized alternative to haemorrhoidectomy, and is associated with reduced pain and earlier return to normal activity. This paper reports all published cases of life-threatening sepsis following stapled haemorrhoidopexy, identifies causative factors and makes recommendations.

METHODS

A systematic review of the literature was performed by searching the major electronic databases. All relevant references were reviewed for possible inclusion. All references of the relevant articles were screened for any further articles that were not identified in the initial search.

RESULTS

From 2000 to the present, 29 articles reporting complications in 40 patients were identified. Thirty-five patients underwent laparotomy with faecal diversion and a further patient was treated by low anterior resection. A specific complication was rectal perforation with peritonitis. Factors that led to life-threatening sepsis were identified in 30 patients. Despite surgical treatment and resuscitation, there were four deaths.

CONCLUSION

Severe sepsis can complicate stapled haemorrhoidopexy. Rectal perforation and peritonitis are a particular risk of this technique and the associated mortality rate is high.

Agraffectomy after low rectal stapling procedures for hemorrhoids and rectocele

BACKGROUND

Various sequelae which might lead to reintervention have been described after stapled rectal mucosectomy for hemorrhoids. One potential treatment modality for persistent complaints after stapled hemorrhoidopexy (SHP) or stapling for rectocele is the so-called agraffectomy (removal of the retained staples). This treatment option means a further procedure that can range from removal of the staples through the anoscope to removal of the entire staple line with the associated scar tissue.

METHODS

In order to review the published literature, we conducted a search on Medline, Pubmed, and Embase using different terms for "agraffectomy."

RESULTS

Overall, fourteen reports were found, dealing with agraffectomy for various conditions after low rectal stapling for hemorrhoids or rectocele. Agraffectomy is a rarely mentioned treatment option for conditions after SHP. In rectal stenosis with complete occlusion of the rectal lumen, the removal of the stenotic anastomosis and remaining staples seems to be reasonable. The same can be said of the removal of retained staples for rectal bleeding or in order to avoid penile injuries in anal intercourse. In contrast, the collected published reports on agraffectomy in this review only provide low-level evidence that this procedure provides relief for other problems such as incontinence or chronic pain.

CONCLUSIONS

There is no clear evidence that agraffectomy is indicated if not in case of rectal stenosis and hemorrhage caused by the staples.

Long-term results after stapled hemorrhoidopexy: a prospective study with a 6-year follow-up

BACKGROUND

Stapled hemorrhoidopexy was introduced in 1998 as a new technique for treating advanced hemorrhoidal disease. Despite a clear perioperative advantage regarding pain and patient comfort, literature reviews indicate a higher recurrence rate for stapled hemorrhoidopexy than for conventional techniques.

OBJECTIVE

Our aim was to present long-term on the use of this technique.

DESIGN

Observational study.

SETTING AND PATIENTS

Consecutive patients with hemorrhoid prolapse treated at a regional surgical center from May 27, 1999, through December 31, 2003.

INTERVENTION

Stapled hemorrhoidopexy with accompanying resection of residual hemorrhoidal nodules if necessary.

MAIN OUTCOME MEASURES

Standardized patient questionnaire regarding satisfaction, resolution of symptoms, and performance of further interventions.

RESULTS

Of 257 patients (82 female, 175 male, mean age 53 ± 13 years) undergoing stapled hemorrhoidopexy, follow-up data were available for 224 patients (87.2%) with a mean duration of 6.3 ± 1.2 years. Of these, 195 patients (87.1%) were satisfied or very satisfied with the operation outcome; 19 patients (8.5%) were moderately satisfied; and 10 (4.5%) were not satisfied. Regarding preoperative anal symptoms, complete relief was observed in 179 patients (80.6%) for prolapse, 172 (77.5%) for bleeding, 139 (85.3%) for mucus discharge, 139 (78.5%) for burning sensation, and 115 (75.5%) for itching. Considering all recorded symptoms, 194 patients (86.6%) reported absence and or an improvement at follow-up. Twelve patients (5.4%) reported newly developed incontinence in the sense of urge symptoms; 42 patients out of 51 patients (82.4%) with preexisting incontinence reported an improvement. Local or topical retreatment (ointment, suppositories, sclerotherapy) was performed in 48 patients (21.4%). Reoperation for residual or newly developed hemorrhoidal nodules was needed in 8 patients (3.6%).

LIMITATIONS

Lack of a comparative group.

CONCLUSION

Our long-term results show that this strategy for stapled hemorrhoidopexy can achieve a high level of patient satisfaction and symptom control, with a low rate of reoperation for recurrent hemorrhoidal symptoms.

Six years after: complications and long-term results after stapled hemorrhoidopexy with different devices

PURPOSE

Stapled hemorrhoidopexy (SH) was introduced in 1998. Early in the experience, a standard circular stapler was often used, while later specifically designed staplers for SH were developed. Although the diameter of the circular cutting knife differ significantly, it remains unclear, if the volume of the excised tissue differs and if this has an influence on the long-term results and complications.

METHODS

We evaluated in a prospective consecutive database that underwent SH from January 2003 through April 2004. There were three devices used during the study period: end-to-end-anastomosis (EEA) 31, stapler device for haemorrhoids (SDH) and procedure for prolapse and haemorrhoids (PPH). Procedure selection was at the discretion of the surgeon; however, the indications for surgery were similar for all involved surgeons. Demographic and operative characteristics were analysed. Follow-up data were collected continuously over the time, and in May 2010, these patients received a questionnaire. Data were compared by t test and chi-square test, respectively.

RESULTS

There were 214 (97 females) evaluable patients. Seventy-three patients were operated with EEA-31, 52 with SDH- and 89 with PPH. The median follow-up was 6.8 years and complete data were available for 131 (61.2%) patients. Demographic characteristics were comparable within the three groups. SDH (6 ml) and PPH (6.5 ml) resected significantly (p < 0.05) more tissue than EEA (5 ml). Early postoperative incontinence rate was significantly higher in the PPH group (6%) as compared to EEA (1%) and SDH (0%). The incidence of other early complications was similar across techniques. The overall complication rates and reoperation rates were similar. Although 41% of the patients had minor anorectal complaints (itching and soiling), incontinence rates were low (2-3%) without any significant differences between the devices.

CONCLUSIONS

The results of cohort of SH patients support the conclusion that short- and long-term outcomes are device independent, although each approach is associated with a modest degree of ongoing anorectal symptoms.

Conversion in transanal stapling techniques for haemorrhoids and anorectal prolapse

AIM

It was the aim of this single-surgeon series to assess the role of conversion in transanal stapling to techniques and to identify potential factors predictive of conversion.

METHOD

The details of all consecutive patients who were planned for a stapled approach were prospectively recorded in a PC database. Stapling techniques (PPH03, PPH01 and ContourTranstar) were indicated for haemorrhoidal disease and internal rectal prolapse. 'Conversion' from a stapled approach was defined as an unplanned change of the surgical method to a nonstapled, traditional technique, related to indication, anatomy and technical factors. The primary outcomes were whether the procedure was performed using a stapling device only, or whether the procedure was converted. Logistic regression analysis was performed to evaluate multiple variables as potential risk factors for conversion.

RESULTS

In a 2-year period (May 2006-May 2008), 258 patients met the inclusion criteria and underwent transanal surgery scheduled as a stapled approach. In these 258 patients, 246 procedures were completed as a stapled procedure [that stapled haemorrhoidopexy, n = 148; stapled mucosectomy, n = 52; stapled transanal rectal resection (STARR) with PPH01, n = 38; and STARR with ContourTranstar, n = 8], giving a completion rate of 95.4%. However, 12 procedures were converted to conventional surgery (including traditional haemorrhoidectomy and the Delorme procedure), giving a conversion rate of 4.6%. The reasons for conversion were related to anatomy and to clinical findings (nonreducible haemorrhoidal prolapse), to new clinical findings not detected preoperatively (proctitis, anal fistula) and to a technical inability to insert the circular anal dilatator because of a deep anal canal. Neither univariate nor multivariate analysis identified any factor to be specifically associated with the risk of conversion.

CONCLUSION

In the era of transanal stapling procedures for haemorrhoids and anorectal prolapse, the majority of procedures can be performed using stapled techniques if strict criteria of indication and patient selection are respected. However, the current study identified a 4.6% conversion rate to traditional treatment, which has an impact on informed consent and requires the surgeon to be familiar with conventional anorectal procedures.

Rectal perforation after procedure for prolapse and hemorrhoids: possible causes

PURPOSE

Our aim was to explore possible causes of rectal perforation occurring in patients who undergo the procedure for prolapse and hemorrhoids.

METHODS

We evaluated data from cases of rectal perforation that occurred after the procedure for prolapse and hemorrhoids in China in conjunction with case reports from the international medical literature.

RESULTS

We identified 7 patients from 5 hospitals in 2 provinces of China who had rectal perforation after the procedure despite having received prophylactic antibiotic treatment. Two patients had a disrupted staple line and 5 had perforations on the rectum wall above the intact staple line. Six patients presented with symptoms in the first 3 days after the procedure. Three patients had concomitant disease: 1 had concomitant constipation and internal rectal prolapse, 1 had concomitant constipation, and 1 had concomitant liver cirrhosis ascites that was not diagnosed preoperatively. Of the 15 cases of rectal perforation found in the literature, 3 patients had an intact staple line and 5 patients had a ruptured staple line.

CONCLUSION

The cone-shaped tip of the anvil, concomitant rectal prolapse and pelvic floor descent, and concomitant ascites are possible causes of rectal perforation after the procedure for prolapse and hemorrhoids.

Stapled haemorrhoidopexy: 6 years' experience of a referral centre

AIM

To prospectively evaluate the long-term results and assess patient satisfaction after stapled haemorrhoidopexy (HS).

METHOD

A total of 150 patients (121 male patients) with symptomatic grade II (n = 50) or III (n = 100) haemorrhoids underwent stapled HS. Patients were followed up during consultations at regular intervals, allowing prospective data collection. A final telephone follow up was also undertaken.

RESULTS

Follow up data were obtained for 130 of 150 patients (86.6%). After a median follow up of 39 months (range, 12-72), 90% of the patients were fully satisfied and 92% were free of haemorrhoidal symptoms. There were no intraoperative complications. Postoperative bleeding that required operation was observed in five patients (3.3%). Most late postoperative complications were benign and easily resolved: unexplained pain for over a month (n = 1), external haemorrhoidal thrombosis (n = 2), anal fissure (n = 6) one with hypertrophic papilla, anal fistula (n = 1), rectal stenosis (n = 1), anal incontinence for (n = 1). Eight patients needed rubber band ligation to treat persistent or recurrent symptomatic prolapse. Four patients (2.6%) were reoperated on during the follow up period but none for haemorrhoidal pathology.

CONCLUSION

Stapled HS procedure is effective and has low morbidity, high patient satisfaction and provided good long-term control of haemorrhoidal symptoms in the treatment of second and third-degree haemorrhoids.

Transanal haemorrhoidal artery echodoppler ligation and anopexy (THD) is effective for II and III degree haemorrhoids: a prospective multicentric study

AIM

We report a multicentric prospective study which aimed to evaluate Doppler-assisted ligation of the terminal haemorrhoidal arteries (THD) for II and III degree haemorrhoids.

METHOD

A total of 112 patients from five colorectal units, including 81 men, mean age 48 +/- 13 years, with II degree (39) and III degree (73) haemorrhoids were treated by Doppler-guided transanal de-arterialization and anopexy using a new device (THD).

RESULTS

The mean operative time was 33.9 +/- 8.8 minutes, and the mean number of ligatures applied was 7.2 +/- 1.5. Postoperatively, 72% of patients did not need analgesics and the other 28% used nonsteroidal antiinflammatory drugs 1-3 times/day for less than 2 days. All the patients were operated as a day case. Early postoperative complications included haemorrhoidal thrombosis (2 patients), bleeding (1) treated by haemostatic suture, dysuria (6) and acute urinary retention (1). After a mean follow-up of 15.6 +/- 6.5 months (range 6-32), 2/105 (20.9%) patients complained of minor bleeding, while mild pain was still present in 4/51 patients (7.8%). There were no statistically significant differences in the sample population regarding the gender or stage of the disease. Tenesmus was cured in 15/17 patients, dyschaezia in 20/22 patients and mucous soiling in 10/10 patients. No new cases of altered defaecation or faecal incontinence were recorded. Overall, 85.7% of patients were cured and 7.1% improved. Residual haemorrhoids were treated by elastic band ligation in nine (8%) patients and by surgical excision in further five patients (4.5%).

CONCLUSION

Doppler-assisted ligation of the terminal branches of the haemorrhoidal arteries for II and III degree haemorrhoids is highly effective and painless. Complications are few and the technique can be performed as a day case.

Staple Line Polyposis and Cytomegalovirus Infection after Stapled Haemorrhoidectomy

Early bleeding after stapled haemorrhoidectomy (SH) is not uncommon. Late and persistent bleeding occurring weeks or months after SH, however, is rare; it has only been described in more than 10% of cases. It is attributed to the development of inflammatory polyps at the staple line. Occurrence of rectal bleeding in the presence of palpable polypoid lesions at the stapled anastomotic line can cause diagnostic confusions, and it is not uncommon that such lesions are initially confused with rectal carcinoma. We report a case of a 38-year-old male who presented with persistent rectal bleeding some 6 months after SH performed in another hospital. Rectal and colonoscopic examinations revealed polypoid lesions at the anastomotic line. The biopsy failed to confirm malignancy, but identified cytomegalovirus (CMV) infection. The development of multiple inflammatory polypoid lesions in conjunction with CMV infection at the stapled anastomotic line has caused a diagnostic confusion, but - after exclusion of cancer - this complication was efficiently treated by CMV infection eradication combined with surgical excision of the remaining polyps due to persistence of bleeding. This case is reported to highlight late bleeding due to inflammatory polyps after SH and to increase the awareness of surgeons and gastroenterologists of this benign but somewhat common complication.

Obstructed Defecation after Stapled Hemorrhoidopexy: A Report of Four Cases

Stapled hemorrhoidopexy or Procedure for Prolapse and Hemorrhoids (PPH) has become an accepted alternative to excisional hemorrhoidectomy for treating prolapsing hemorrhoids. Although rare, severe complications have been reported after this procedure. We report a series of four male patients with the unusual but debilitating symptoms of obstructed defecation (OD) after PPH. Presenting symptoms included evacuation difficulty, rectal pain, and urgency. All had scarring and stenosis at their PPH anastomotic staple line with a resultant ball-valve effect in three patients as the mobile, excessive, proximal rectal mucosa prolapsed past this relatively immobile area. The fourth patient had an anterior rectal mucosal pouch distal to the PPH staple line. In three of the four patients the anastomosis was below the dentate line or on an oblique angle. Corrective operative intervention largely relieved OD symptoms. One patient, more refractory to successful revision, was eventually diagnosed and treated successfully for pudendal neuropathy. Avoidance of the complication of OD is possible through careful patient selection, proper operative technique, and consideration of nonsurgical etiologies. These complications are complex in nature but most patients will respond to an individualized treatment plan that combines surgical and medical interventions.

Residual skin tags following procedure for prolapse and hemorrhoids: differentiation from recurrence

PURPOSE

The aim of this study was to compare the incidence of recurrence and residual skin tag after the procedure for prolapse and hemorrhoids (PPH) versus conventional hemorrhoidectomy (CH) in the Chinese- and English-language literature to explore the definition of recurrence after PPH.

METHODS

Related Chinese- and English-language literature was collected by several methods. Meta-analysis was used to compare the incidence of recurrence and residual skin tag of PPH versus CH.

RESULTS

In China, 13.94% of hemorrhoids had a skin tag after PPH. The mean recurrence rate after PPH was 3.23% (range 0.40-26.44%). Our meta-analysis of PPH versus CH of the Chinese studies showed that PPH had a significantly lower recurrence rate-13 studies, odds ratio (OR) 0.27, 95% confidence interval (CI) 0.17-0.42, p < 0.00001-and a higher incidence of skin tags with no significance-6 studies, OR 3.42, 95% CI 0.49-24.04, p = 0.22. Our meta-analysis of PPH versus CH among the English-language studies showed that PPH had a significantly higher recurrence rate-17 studies, 636 patients in the PPH group vs. 625 patients in the CH group, OR 2.96, 95% CI 1.57-5.56, p = 0.0008-and a significantly higher incidence of residual skin tags-8 studies, 297 patients in the PPH group vs. 289 patients in the CH group, OR 1.88, 95% CI 1.15-3.05, p = 0.01. However, the recurrence of prolapse was stated to be ascertained by anorectal examination in only six studies; meta-analysis of the six studies showed that PPH was not associated with a higher recurrence-six studies, 230 patients in the PPH group vs. 220 patients in the CH group; OR 1.87, 95% CI 0.70-5.00, p = 0.22.

CONCLUSIONS

PPH is not associated with a higher recurrence rate but is associated with a higher incidence of skin tags compared with CH. The reported high recurrence rates are probably caused by improper inclusion of residual skin tags into the recurrence data. Surgeons should perform anorectal examinations to differentiate a residual skin tag from a recurrence.

Complications, recurrences, early and late reoperations after stapled haemorrhoidopexy: lessons learned from 1,233 cases

PURPOSE

The purpose of the study was to analyse the outcomes of all patients requiring a reoperation after an initial circular stapled haemorrhoidopexy (SH) for prolapsing haemorrhoids.

METHODS

Data of all patients undergoing a circular SH from 1998 thru 2007 available in a prospectively collected database were reviewed, and all patients who had reoperations were studied.

RESULTS

During the study period, 1,233 patients (551 females, median age 52 years) underwent a circular SH. Complete follow-up was available in all patients (median follow-up 7 months, range 0.5-100); 127 patients (10.3%) required one or more reoperations. Early reoperations (<30 days) were necessary in 47 patients (3.8%), and 45 (3.6%) were stapler-related complications. Late reoperations (>30 days) were performed in 84 patients (6.8%) and 57 (4.6%) were stapler-related. A learning curve was observed with significant reduction of early (<30 days) and late (>30 days) reoperation rate with time.

CONCLUSIONS

Reoperations after SH are necessary in about 10% of the patients. The majority of the reoperations are due to either complications arising from circular SH, recurrent/persistent haemorrhoidal symptoms or other anorectal issues not addressed by the circular SH procedure (3.8% early; 6.8% late). Circular SH appears to be an effective procedure for symptomatic haemorrhoidal disease; however, training and learning curve issues should be addressed to minimise treatment failures.

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.

Obliteration of the rectal lumen after stapled hemorrhoidopexy: report of a case

We report an incident of complete stapled closure of the rectal lumen following stapled hemorrhoidopexy. A patient with symptomatic prolapsing hemorrhoids underwent a stapled hemorrhoidopexy as a day-case procedure. After application of the pursestring suture and firing of the dedicated stapler the rectal lumen was found to have been completely obliterated. Endoscopic assessment using a flexible sigmoidoscope confirmed the absence of a rectal lumen. The patient was woken up and a gastrograffin enema performed. Contrast was injected under high pressure into the rectal lumen and a small defect in the mid point of the staple line was revealed. A fine guidewire was passed and endoscopic balloon dilatation achieved. This complication could have had catastrophic consequences and potentially required major surgical intervention. Although unlikely to occur, we believe that surgeons should be aware of this possible problem and a radiologic/endoscopic approach should be considered before more aggressive surgical intervention is undertaken.

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.

Transanal haemorrhoidal dearterialisation: nonexcisional surgery for the treatment of haemorrhoidal disease

BACKGROUND

Transanal haemorrhoidal dearterialisation (THD) is a nonexcisional surgical technique for the treatment of piles, consisting in the ligation of the distal branches of the superior rectal artery, resulting in a reduction of blood flow and decongestion of the haemorrhoidal plexus. The aim of this study was to assess the long-term efficacy of this treatment.

METHODS

The procedure was carried out using a proctoscope with a Doppler probe. The terminal branches were located with Doppler and then sutured.

RESULTS

From January 2000 to May 2006, we performed THD in 330 patients (180 men; mean age, 52.4 years), including 138 second-degree, 162 third-degree and 30 fourth-degree haemorrhoids. There were 23 postoperative complications (7 cases of bleeding, 5 thrombosed piles, 4 rectal haematomas, 2 anal fissures, 2 cases of dysuria, 1 of haematuria and 2 needle ruptures). The mean postoperative pain score was 1.32 on a visual analog scale. 219 patients were followed for a mean of 46 months (range, 22-79), including 100 patients with second-degree, 104 with third-degree and 15 with fourth-degree haemorrhoids. The operation completely resolved the symptoms in 132 patients (92.5%) with preoperative bleeding and in 110 patients (92%) with preoperative prolapse.

CONCLUSIONS

The efficacy and relapse rate of this procedure appears to be similar to that of traditional surgery and stapled haemorrhoidopexy. The technique was effective and safe for all degrees of haemorrhoids because of the excellent results, low complication rate and minor postoperative pain.

Stapled hemorrhoidopexy for prolapsed hemorrhoids in patients with liver cirrhosis; a preliminary outcome for 8-case experience

PURPOSE

To investigate the efficacy and safety of stapled hemorrhoidopexy in treating prolapsed hemorrhoids in patients with liver cirrhosis.

PATIENTS AND METHODS

Eight consecutive cases of patients with prolapsed hemorrhoids comorbid with liver cirrhosis, who had intractable response to other interventions, were enrolled in this retrospective study between January 2002 and June 2006 at our institute. Six patients (75%) had Child-Pugh class A liver cirrhosis, whereas only two patients (25%) had class B disease. Rectal varices were identified in three patients (37.5%), and esophageal varices were identified in six patients (75%). Concurrent rectal and esophageal varices existed in three patients (37.5%). The patients underwent stapled hemorrhoidopexy with Proximate PPH-03 in a lithotomy position under spinal/intravenous general anesthesia.

RESULTS

There was no procedure-related mortality or major complications except hemorrhage. Two patients (25%) were complicated with postoperative staple-line bleeding, which was managed with conservative treatment without reoperation. There were no leading symptoms of relapsing during a follow-up period of at least 6 months.

CONCLUSIONS

This study may prove that stapled hemorrhoidopexy is a feasible and safe approach for prolapsed hemorrhoids concurrent with liver cirrhosis.

Randomized comparison between stapled hemorrhoidopexy and Ferguson hemorrhoidectomy for grade III hemorrhoids in Taiwan: a prospective study

PURPOSE

Short-term and mid-term outcomes of stapled hemorrhoidopexy (SH) were compared with those for Ferguson hemorrhoidectomy (FH) for treating hemorrhoids.

MATERIALS AND METHODS

Patients with prolapsed hemorrhoids were randomized into two groups treated with SH (N = 300) and FH (N = 296) at Chang Gung Memorial Hospital at Chiayi in Taiwan between January 2002 and December 2004. The outcomes of the procedures were evaluated postoperatively (short-term, i.e., intra-/postoperative conditions, hospital stay, pain intensity scoring, time off work, and procedure-related morbidity) and over a follow-up period of minimum 18 months (mid-term, i.e., relapse of prolapse and/or bleeding, anal stricture, anal sepsis, and the acceptability of the procedures to the patients).

RESULTS

SH was superior to FH in operative time, intraoperative blood loss, postoperative pain intensity, and return to work. Based on telephone interviews over the follow-up period, most patients who received SH appreciated the procedure better than those with FH.

CONCLUSIONS

This study confirms that SH generates less postoperative suffering, less time off work, and more complete resolution of primary symptoms associated with hemorrhoids in the mid-term follow-up than FH.

Stapled transanal rectal resection versus stapled anopexy in the cure of hemorrhoids associated with rectal prolapse. A randomized controlled trial

PURPOSE

A remarkable incidence of failures after stapled axopexy (SA) for hemorrhoids has been recently reported by several papers, with an incomplete resection of the prolapsed tissue, due to the limited volume of the stapler casing as possible cause. The stapled transanal rectal resection (STARR) was demonstrated to successfully cure the association of rectal prolapse and rectocele by using two staplers. The aim of this randomized study was to evaluate the incidence of residual disease after SA and STARR in patients affected by prolapsed hemorrhoids associated with rectal prolapse.

METHODS

Sixty-eight patients were selected on the basis of validated constipation and continence scorings, clinical examination, colonoscopy, anorectal manometry, and defecography and randomized: 34 underwent a SA and 34 a STARR operation. The operated patients were followed-up with clinical examination, visual analog scale for postoperative pain, a satisfaction index, and defecography.

RESULTS

At a mean follow-up of 8.1+/-2.0 and 7.9+/-1.8 months for the SA and STARR groups, respectively, the incidence of residual disease was significantly higher in the first group (29.4 vs 5.9 in the STARR group, p=0.007), while a significantly lower incidence of residual skin-tags was found after STARR (23.5% vs 58.8 after SA, p=0.03). All patients with residual disease showed prolapsed tissue over half the length of the anal dilator at the time of the operation. Operative time and incidence of transient fecal urgency were significantly higher in the STARR group (with p=0.001 and 0.08, respectively), while SA was followed by a significantly higher incidence of poor results at the overall patient satisfaction index (p=0.04). No significant differences were found in hospital stay, operative complications, postoperative pain, time to return to normal activity, continence, and constipation scores. All the defecographic parameters significantly improved after STARR, while SA was followed only by a trend to a reduction of rectal prolapse.

CONCLUSIONS

STARR provides a more complete resection of the prolapsed tissue than SA in patients with association of prolapsed hemorrhoids and rectal prolapse with equal morbidity and significantly lower incidence of residual disease and skin-tags. The anal dilator can be used for selecting the surgical technique.