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

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.

Stapled hemorrhoidopexy for hemorrhoids: A overview of systematic reviews and meta-analysis

Stapled hemorrhoidopexy has been used for years to treat hemorrhoids. Despite numerous systematic reviews and meta-analyses on the topic, inconsistent conclusions have left people uncertain about its effectiveness and raised doubts about the quality of these reviews.In order to provide reliable evidence for clinical practice, it is crucial to conduct an overview to assess the quality of MAs/SRs regarding the efficacy and complications of SH.A comprehensive search was performed across seven databases to identify MAs/SRs on the efficacy and complications of SH from inception to October 2023. The selected MAs/SRs were then assessed using three well-established tools: AMSTAR-2, PRISMA 2020and GRADE. These assessments provide a robust evaluation of the quality and reliability of the included MAs/SRs.We removed overlapping randomized controlled trials (RCTs) and conducted a new meta-analysis of the outcomes. The overview included 23 meta-analyses.In AMSTAR-2, three reviews were deemed moderate quality, nine reviews were classified as low quality, and eleven reviews were evaluated as critically low quality.In PRISMA 2020,certain deficiencies were exhibited, such as abstracts (0/23:0 %),final retrieval date (0/23:0 %), sensitivity analysis (6/23:26.09 %),publication bias assessment (11/23:47.83 %), the quality of evidence (2/23:8.70 %) and so on.In GRADE,twenty-six items were rated as moderate quality (27.96 %),forty-one items were rated as low quality (44.09 %) and twenty-six items were rated as critically low quality (27.96 %).SH has been found to be an effective intervention for reducing postoperative pain, shortening procedure time, and promoting wound healing. The re-analysis indicated that SH can reduce postoperative pain in hemorrhoid patients (odds ratio = 0.28, 95 % confidence interval [0.15,0.55], p = 0.0002; I2 = 74 %, p < 0.00001). But SH is associated with a higher risk of postoperative bleeding and recurrence of prolapse.Given that the reviews included in this overview were rated as low quality, caution should be exercised when interpreting the findings.

Delorme's vs. Altemeier's in the management of rectal procidentia: systematic review and meta-analysis

BACKGROUND

Rectal prolapse is a distressing condition for patients and no consensus exists on optimal surgical management. We compared outcomes of two common perineal operations (Delorme's and Altemeier's) used in the treatment of rectal prolapse.

METHODS

A systematic search of multiple electronic databases was conducted. Peri- and post-operative outcomes following Delorme's and Altemeier's procedures were extracted. Primary outcomes included recurrence rate, anastomotic dehiscence rate and mortality rate. The secondary outcomes were total operative time, volume of blood loss, length of hospital stay and coloanal anastomotic stricture formation. Revman 5.3 was used to perform all statistical analysis.

RESULTS

Ten studies with 605 patients were selected; 286 underwent Altemeier's procedure (standalone), 39 had Altemeier's with plasty (perineoplasty or levatoroplasty), and 280 had Delorme's. Recurrence rate [OR: 0.66; 95% CI [0.44-0.99], P = 0.05] was significantly lower and anastomotic dehiscence [RD: 0.05; 95% CI [0.00-0.09], P = 0.03] was significantly higher in the Altemeier's group. However, sub group analysis of Altemeier's with plasty failed to show significant differences in these outcomes compared with the Delorme's procedure. Length of hospital stay was significantly more following an Altemeier's operation compared with Delorme's [MD: 3.05, 95% CI [0.95 - 5.51], P = 0.004]. No significant difference was found in total operative time, intra-operative blood loss, coloanal anastomotic stricture formation and mortality rates between the two approaches.

CONCLUSIONS

A direct comparison of two common perineal procedures used in the treatment of rectal prolapse demonstrated that the Altemeier's approach was associated with better outcomes. Future, well-designed high quality RCTs with long-term follow up are needed to corroborate our findings.

Prevention of Rectal Stenosis After Procedure for Prolapse and Hemorrhoids by Anastomotic Thread-Drawing and Anal Enlargement

PURPOSE

to investigate preventive measures of rectal stricture after procedure for prolapse and hemorrhoids (PPH) and to intervene early.

METHODS

A total of 400 patients with severe mixed hemorrhoids hospitalized in the [anonymous hospital] from January 2018 to February 2022 were randomly divided into the experimental group and control group A, B, and C, with 100 patients in each group. Experimental group: Thread-drawing during operation and anal enlargement after PPH. Group A: Thread-drawing during PPH surgery, group B: Anal enlargement after PPH, and group C: PPH alone. The anastomotic sites of the 4 groups were observed for 1-2 months and followed up for 1-3 years.

RESULTS

The effective rate of mixed hemorrhoid treatment in the 4 groups was 100%. There was no rectal stenosis in the experimental group, 11% in group A, 7% in group B, and 14% in group C.

CONCLUSION

Multipoint thread-drawing and anal enlargement after PPH can avoid postoperative rectal stenosis and can strengthen anastomosis and reduce bleeding, while being a simple procedure that can be easily popularized.

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.

Efficacy and safety of Lingnan surgery for the treatment of multi-quadrant acute incarcerated hemorrhoids: A retrospective study

OBJECTIVE

In this study, we introduce a surgical procedure for multiple-quadrant hemorrhoid crisis, namely Lingnan surgery, and discuss its clinical efficacy and safety.

METHODS

We performed a retrospective analysis of patients with acute incarcerated hemorrhoids who underwent Lingnan surgery at the Anorectal Department of Yunan County Hospital of Traditional Chinese Medicine of Guangdong Province from 2017 to 2021. The baseline data, preoperative condition, and postoperative condition of each patient were recorded in detail.

RESULTS

A total of 44 patients were studied. There were no cases of massive hemorrhage, wound infection, wound nonunion, anal stenosis, abnormal anal defecation, recurrent anal fissure, or mucosal eversion within 30 days after surgery, and no recurrence of hemorrhoids and anal dysfunction occurred during the 6-month follow-up after surgery. The average operation time was 26.5 ± 6.2 min (17-43 min). The average length of hospital stay was 4.0 ± 1.2 days (2-7 days). In terms of postoperative analgesia, 35 patients took oral nimesulide, 6 did not use any analgesics, and 3 required nimesulide plus tramadol by injection. The mean Visual Analog Scale pain score was 6.8 ± 0.8 preoperatively and 2.9 ± 1.2, 2.0 ± 0.7, and 1.4 ± 0.6 at 1, 3, and 5 days postoperatively, respectively. The average basic activities of daily living score was 98.2 ± 2.6 (90-100) at discharge.

CONCLUSION

Lingnan surgery is easy to perform and has obvious curative effects, providing an alternative to conventional procedures for acute incarcerated hemorrhoids.

Perirectal hematoma after stapled surgery for hemorrhoidal prolapse and obstructed defecation syndrome: case series management to avoid panic-guided treatment

Perirectal hematoma (PH) is one of the most feared complications of stapling procedures. Literature reviews have reported only a few works on PH, most of them describing isolated treatment approaches and severe outcomes. The aim of this study was to analyze a homogenous case series of PH and to define a treatment algorithm for huge postoperative PHs. A retrospective analysis of a prospective database of three high-volume proctology units was performed between 2008 and 2018, and all PH cases were analyzed. In all, 3058 patients underwent stapling procedures for hemorrhoidal disease or obstructed defecation syndrome with internal prolapse. Among these, 14 (0.46%) large PH cases were reported, and 12 of these hematomas were stable and treated conservatively (antibiotics and CT/laboratory test monitoring); most of them were resolved with spontaneous drainage. Two patients with progressive PH (signs of active bleeding and peritonism) were submitted to CT and arteriography to evaluate the source of bleeding, which was subsequently closed by embolization. This approach helped ensure that no patients with PH were referred for major abdominal surgery. Most PH cases are stable and treatable with a conservative approach, evolving with self-drainage. Progressive hematomas are rare and should undergo angiography with embolization to minimize the possibility of major surgery and severe complications.

Mucocele: a rare complication following stapled haemorrhoidopexy

Background

Stapled haemorrhoidopexy (SH) has resulted in a unique collection of procedural complications with postoperative mucocele a particularly rare example. This study is designed to comprehensively describe the characteristics of rectal mucocele and discuss its pathogenesis following SH surgery.

Methods

A database of patients presenting with a rectal mucocele following an SH procedure was established and studied retrospectively.

Results

Seven patients (5 males; median age 32 years, range 20–75 years) were identified. All patients complained of variable anal discomfort with 5/7 presenting with inconstant anal pain, 2 with de novo evacuatory difficulty. These cases appeared at a median time of 6 months (range 2–84 months) after SH surgery.

Conclusion

Rectal Mucocele develops when mucosal fragments become embedded and isolated under the mucosa. It is a preventable complication of SH surgery by ensuring correct purse string placement prior to stapled haemorrhoid excision.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01744-3.

Top 100 most-cited articles on hemorrhoids: A bibliometric analysis and visualized study

Background

Hemorrhoids have a significant incidence in people and are becoming a common public health problem. This study provides a bibliometric and visualized analysis of the most influential literature in the field. The aim is to reveal trends in the field of hemorrhoids and to provide a reference for researchers.

Methods

The 100 most frequently cited studies in the field of hemorrhoids were collected from the Web of Science(WOS), and were analyzed in terms of the annual publication, types of literature, countries, institutions, authors, journals, and keywords. During the study, we used a combination of VosViewer, Carrot2, Microsoft Excel, and Tableau tools to better present the visual information.

Results

A total of 4,481 articles were retrieved, of which 3,592 were of the Article and Review types, among which we selected the 100 most frequently cited. A large amount of highly cited literature on hemorrhoid surgery emerged from 1990 to 2010, and the interest of researchers in hemorrhoid surgery seems to have waned after 2010. The sources of highly cited literature in the field of hemorrhoids are predominantly Western, with the United States. and the United Kingdom accounting for almost half of the publications worldwide. However, countries with higher prevalence populations do not have significant research on hemorrhoids. St. Mark's Hospital has published the largest number of influential articles in the field of hemorrhoid disease. Kamm MA and Phillips RKS are the most authoritative authors in the field. Diseases of the Colon & Rectum and the British Journal of Surgery are the most influential journals in this field. The highly cited literature covers a wide range of disciplines, with Thomson's classic “The nature of hemorrhoids” receiving the most attention among the studies focusing on hemorrhoids. Keyword and clustering analysis revealed that The most famous focus in the field of hemorrhoid research is the evolution of stapled hemorrhoidectomy (SH) and Milligan-morgan hemorrhoidectomy (MMH).

Conclusions

This study is the first to explore developments in the field of hemorrhoids, and it helps surgeons quickly understand global trends in the field of hemorrhoids. In recent years, the development of hemorrhoids seems to have hit a bottleneck, with scholarly interest in the field of waning, especially in surgery Procedures. The theory of inferior anal cushion migration has proven to be the most influential theory in the field, but after studies based on SH and MMH, more high-quality evidence is needed to continue advancing the field of hemorrhoids. The results of this study are intended to add to the attention and interest of scholars in this area and provide a reference for further research.

Time trend in the surgical management of obstructed defecation syndrome: a multicenter experience on behalf of the Italian Society of Colorectal Surgery (SICCR)

Background

Surgical management of obstructed defecation syndrome (ODS) is challenging, with several surgical options showing inconsistent functional results over time. The aim of this study was to evaluate the trend in surgical management of ODS in a 10-year timeframe across Italian referral centers.

Methods

Surgeons from referral centers for the management of pelvic floor disorders and affiliated to the Italian Society of Colorectal Surgery provided data on the yearly volume of procedures for ODS from 2010 to 2019. Six common clinical scenarios of ODS were captured, including details on patient’s anal sphincter function and presence of rectocele and/or rectal intussusception. Perineal repair, ventral rectopexy (VRP), transanal repair (internal Delorme), stapled transanal rectal resection (STARR), Contour Transtar, and transvaginal repair were considered in each clinical scenario.

Results

Twenty-five centers were included providing data on 2943 surgical patients. Procedure volumes ranged from 10–20 (54%) to 21–50 (46%) per year across centers. The most performed techniques in patients with good sphincter function were transanal repair for isolated rectocele (243/716 [34%]), transanal repair for isolated rectal intussusception (287/677 [42%]) and VRP for combined abnormalities (464/976 [48%]). When considering poor sphincter function, these were perineal repair (112/194 [57.8%]) for isolated rectocele, and VRP for the other two scenarios (60/120 [50%] and 97/260 [37%], respectively). The use of STARR and Contour Transtar decreased over time in patients with impaired sphincter function.

Conclusions

The complexity of ODS treatment is confirmed by the variety of clinical scenarios that can occur and by the changing trend of surgical management over the last 10 years.

Association of Muscle Fibers with Histopathology in Doughnut Specimens Following Stapled Hemorrhoidopexy and Their Impacts on Postoperative Outcomes

Background Stapled hemorrhoidopexy is widely practiced worldwide since its introduction to the world of proctology and replaced conventional hemorrhoidectomy in treating hemorrhoids. The technique of executing the procedure dictates the outcomes and complications. Here, we attempted to establish the cause of postoperative complications and attributed them to the presence of muscle of fibers in the excised doughnut specimens.

Materials and Methods A prospective observational analysis of histopathological specimens obtained from patients who underwent stapled hemorrhoidopexy using procedure for prolapse and hemorrhoids-03 circular staplers in the department of surgery of a tertiary care hospital in southern India was performed, and the correlation between the presence or absence of muscle fibers in the specimens and postoperative complications was evaluated. The patients were followed up for 12 months after the procedure.

Results In this study, 155 patients, including 54, 91, and 10 patients with Grade 2, Grade 3, and Grade 4 hemorrhoids, respectively, were included. Group A consisted of 19 patients with muscle fibers on the specimens, whereas Group B consisted of 139 patients without muscle fibers on the specimens. Early complications within 7 days after the procedure were as follows: 21 and 0.7% of the patients in Groups A and B, respectively, presented with postoperative pain with a visual analog scale score of more than 4; 47 and 6% of the patients in Groups A and B, respectively, presented with urinary retention; 26 and 2% of the patients in Groups A and B, respectively, presented with bleeding; and 21 and 2.9% of the patients in Groups A and B, respectively, presented with fecal urgency. A significant association was found between the presence of muscle fibers and early complications (p < 0.001). Late complications, such as proctalgia and bleeding, accounting for 36.8 and 6.6% in Groups A and B, respectively, were significantly associated with the presence of muscle fibers in histopathology (p < 0.001). Meanwhile, other late complications, such as incontinence, stenosis, and recurrence, exhibited no association (p > 0.05).

Conclusion The technique in taking purse-string sutures and the depth of the suture bite above the dentate line carry the utmost importance in preventing postoperative complications. Therefore, surgeons should refine their technique of appropriate depth to avoid incorporation of muscle fibers while executing the procedure.

Transanal Suture Mucopexy for Hemorrhoids

BACKGROUND

Core factors involved in the treatment of hemorrhoids include the engorgement of hemorrhoids, prolapse, recurrence, and pain.

OBJECTIVE

The goal of this study was to assess the safety, pain, and efficacy of the transanal suture mucopexy for the treatment of hemorrhoids.

DESIGN

This was a retrospective study over a 13-year period.

SETTING

This procedure was performed, and data collected, from medical records at six centers in India.

PATIENTS

This study includes 5634 patients who had grade II to IV symptomatic hemorrhoids. Patients suffering from thrombosed hemorrhoids, inflammatory bowel disease, anal strictures, and anorectal carcinoma were excluded.

INTERVENTIONS

Hemorrhoidal swelling was reduced by manual massage and a steep Trendelenburg position under saddle block. The reduced hemorrhoids were fixed to the muscles of the rectal wall using sutures. Each suture measured 0.5 to 1.0 cm in length; double-locking continuous sutures were used, along the complete circumference of the rectum, at 2 and 4 cm proximal to the dentate line.

MAIN OUTCOME MEASURES

Pain assessed using the visual analog scale and hemorrhoid recurrence served as outcome measures.

RESULTS

The transanal suture mucopexy procedure was performed for 5634 patients with symptomatic hemorrhoids. A dull pain compatible with a visual analog score of 2 to 3 was reported in 126 (2.2%) patients; in the remaining 5508 (97.8%) patients, the visual analog score was 1 to 2. Effective treatment without complications occurred for 5541 patients (98.65%). A recurrence rate of 1.3% was recorded in 5634 cases with a mean follow-up of 7 ± 6 years.

LIMITATIONS

Utilization of a self-illuminating proctoscope or Brinckerhoff or anal speculum is essential.

CONCLUSION

Transanal suture mucopexy, designed with 2 suture rows, is a safe procedure with a short learning curve. It is associated with minimal pain, low recurrence rate, and fewer complications. See Video Abstract at http://links.lww.com/DCR/B841.

MUCOPEXIA TRANSANAL CON SUTURA PARA ENFERMEDAD HEMORROIDAL

ANTECEDENTES:Los factores centrales involucrados en el tratamiento de la enfermedad hemorroidal incluyen congestión de hemorroides, prolapso, recurrencia y dolor.OBJETIVO:Evaluar la seguridad, el dolor y la eficacia de la mucopexia transanal con sutura para el tratamiento de la enfermedad hemorroidal.DISEÑO:Estudio retrospectivo durante un período de 13 años.ESCENARIO:Este procedimiento se realizó y se recopilaron datos de expedientes médicos en seis centros en India.PACIENTES:Este estudio incluye 5634 pacientes con enfermedad hemorroidal sintomática grado II a IV. Se excluyeron pacientes que padecían hemorroides trombosadas, enfermedad inflamatoria intestinal, estenosis anales y carcinoma anorrectal.INTERVENCIONES:La inflamación hemorroidal se redujo mediante masaje manual y posición Trendelenburg profundo bajo bloqueo caudal. Las hemorroides reducidas se fijaron a los músculos de la pared rectal mediante suturas. Cada sutura midió 0.5 a 1.0 cm de longitud, se utilizaron suturas en surgete continuo de doble anclado, a lo largo de la circunferencia completa del recto, a dos y cuatro cm proximales a la línea dentada.PRINCIPALES MEDIDAS DE RESULTADO:El dolor se evaluó mediante la escala de puntuación analógica visual y se evaluó la presencia de recurrencia.RESULTADOS:El procedimiento de mucopexia transanal con sutura se realizó en 5634 pacientes con hemorroides sintomáticas. Se informó un dolor sordo compatible con una puntuación analógica visual de 2-3 en 126 (2.2%) pacientes; en los 5508 (97.8%) pacientes restantes, la puntuación analógica visual fue de 1-2. La mayoría (5541 pacientes [98.65%]) tuvo un tratamiento eficaz sin complicaciones. Se registró una tasa de recurrencia del 1.3% en 5634 casos con un seguimiento medio de 7 ± 6 años.LIMITACIONES:La utilización de un proctoscopio autoiluminado o de Brinckerhoff o espéculo anal es esencial.CONCLUSIÓN:La mucopexia transanal con sutura es un procedimiento seguro diseñado con dos filas de suturas asociadas con dolor mínimo y baja tasa de recurrencia con menos complicaciones. Tiene una curva de aprendizaje corta. Consulte Video Resumen en http://links.lww.com/DCR/B841. (Traducción-Dr. Jorge Silva Velazco).

Indications, Feasibility, and Safety of TST STARR Plus Stapler for Degree III Hemorrhoids: A Retrospective Study of 125 Hemorrhoids Patients

Background

Stapler hemorrhoidopexy (SH) has been widely accepted for hemorrhoids patients because of its low postoperative pain, but it is also associated with a high recurrence rate. The recurrence might be due to failure to completely remove the prolapsed tissue or insufficient removal capacity of the instruments. Removing more prolapsed tissue to reduce the recurrence is believed to benefit more severe prolapsed hemorrhoids patients.

Methods

We evaluated the short- and long-term safety and efficacy in 125 hemorrhoids patients who underwent SH in 2013–2015. Eighty patients had prolapsed tissue less than half of the circular anal dilator (CAD) and underwent a procedure for prolapsing hemorrhoids (PPH), while the remaining 45 patients with hemorrhoid prolapse greater than half of the CAD were treated with a tissue selection therapy stapler stapled transanal rectal resection plus (TST STARR+).

Results

There were no significant differences between the two groups in terms of operative time, hospitalization time, overall satisfaction or complications. At follow-up of up to 4 years after surgery, there was no significant difference in recurrence rates between TST STARR+ group and PPH group (5.2% vs. 4.7%, p < 0.05). The mean width and volume of the resected tissues were significantly larger in the TST STARR+ group than in the PPH group (4.8 vs. 2.9 cm, 10.2 vs. 4.4 cm³, P < 0.05).

Conclusion

The TST STARR+ procedure can remove more hemorrhoidal tissue than PPH and it is better suited for patients with severe annular prolapsed hemorrhoids greater than half of the CAD. It has the advantages of convenient to operate, rapid recovery, fewer complications, and long-term satisfactory results.

Comparison of the outcomes of hemorrhoidectomy and PPH in the treatment of grades III and IV hemorrhoids

ABSTRACT

To investigate the clinical effect and outcome of traditional hemorrhoidectomy and procedures for prolapse and hemorrhoid (PPH) for the treatment of grades III and IV hemorrhoids.We retrospectively reviewed 1003 grades III and IV hemorrhoid patients who presented to our hospital. A total of 585 patients underwent PPH, and 418 patients underwent hemorrhoidectomy. The outcomes were 1-year recurrence, postoperative complications, surgery-related complications, and indicators.No significant difference between the 2 treatment groups regarding patient demographics. All patients underwent more than 12months of postoperative follow-up. No significant difference between the 2 treatment groups in 1-year recurrence. PPH can markedly improve anal pain, postoperative bleeding, difficult urination, and postoperative resting anal pressure. The operative blood loss, operative time, wound healing time, and wound infection rates were decreased significantly in the PPH group compared with the traditional hemorrhoidectomy group.Our data suggest that PPH is useful and safe for grades III and IV hemorrhoids. It can reduce postoperative and surgery-related complications. However, this was a single-hospital retrospective study. Therefore, well-designed, multicenter, randomized controlled trials are needed to evaluate the value of PPH for grades III and IV hemorrhoids.

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.

STAPLED HEMORRHOIDOPEXY: RESULTS, LATE COMPLICATIONS, AND DEGREE OF SATISFACTION AFTER 16 YEARS OF FOLLOW-UP

Stapled hemorrhoidopexy has been widely used for the treatment of hemorrhoids, but concerns about complications and recurrences after prolonged follow-up are still under debate.

Pneumoretroperitoneum after a STARR Procedure Performed One Year after a Posterior Colporrhaphy: A Case Report and Review of the Literature

Transanal rectal resection with a stapling instrument (STARR) has been shown to be effective and safe for the treatment of obstructed defecation syndrome (ODS). Nevertheless, the wide range of complications described in the literature necessitates a rigorous patient selection and a tailored approach for the management of complications. We present here a case of pneumoretroperitoneum which occurred after a STARR procedure for ODS was performed nearly a year after previous anterior and posterior colporrhaphy. The diagnostic workup did not reveal a staple-line defect. Laparoscopy did not show any intra-abdominal pathology. The symptoms resolved under oral antibiotics. The patient was discharged on day 10 after admission. Scarring in the rectovaginal septum from a colporrhaphy 1 year earlier might have contributed to a suboptimal staple-line closure during the STARR procedure, leading to a pneumoretroperitoneum. We discuss this complication and provide a brief review of the literature.

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.

Improvement in Hemorrhoidal Disease Surgery Outcomes Using a New Anatomical/Clinical-Therapeutic Classification (A/CTC)

Introduction  The introduction and diffusion of new techniques for hemorrhoidal surgery have made it clear how much Goligher classification is inadequate in the modern times, lacking in any correlation between anatomical and clinical features to a surgical procedure. The aim of the study was to evaluate if the application of a new classification of hemorrhoidal diseases might lead to an improvement in the postoperative surgical outcomes.

Methods  From January 2014 to December 2015, all patients undergoing surgery for hemorrhoidal disease were enrolled. The procedures performed were based upon a new anatomical/clinical–therapeutic classification (A/CTC) considering these items: anatomical presentation, symptom types and frequency, associated diseases, and available surgical treatments and their related contraindications. The new classification identified four groups: A (outpatient), B, C, and D (surgical approaches). The overall outcomes were assessed and then stratified by surgical groups. These data were then analyzed in comparison with the published data about all the surgical procedures performed.

Results  A total of 381 patients underwent surgery and they were stratified as follows: Group B (39), C (202), and D (140). Group B underwent Doppler-guided dearterialization with mucopexies or tissue selective therapy, Group C stapled procedures, and Group D hemorrhoidectomy. The mean follow-up was 30 months. The overall outcomes were: success rate 92.4%, recurrences 7.6%, postoperative complications 4.8%, long-term complications 5.4%, and reoperation rate 2.7%. The success rates stratified by groups were: B, 85%); C, 91.4%; and D, 95.7%.

Conclusion  The A/CTC proved to be useful in stratifying the patients and choosing the proper treatment for each case. This classification seems to improve the outcome of different surgical procedures if compared with those already published.

TRANSANAL HAEMORRHOIDAL DEARTERIALIZATION WITH MUCOPEXY (THD-M) FOR TREATMENT OF HEMORRHOIDS: IS IT APPLICABLE IN ALL GRADES? BRAZILIAN MULTICENTER STUDY

Background:

Transanal haemorrhoidal dearterialization with mucopexy (THD-M) is a valuable option for treating patients with haemorrhoidal disease. However, there is still controversy with regard to its efficacy for more advanced grades.

Aim:

To evaluate the effectiveness of THD-M technique for treating hemorrhoidal disease and to compare the immediate and late results in different grades.

Method:

Seven hundred and five consecutive patients with Goligher’s grade II, III or IV symptomatic haemorrhoids underwent surgical treatment using the THD-M method in five participating centres. Six well-trained and experienced surgeons operated on the patients. Average follow-up was 21 months (12-48).

Results:

Intraoperative complications were observed in 1.1% of cases, including four cases of haematoma, two of laceration of the mucosa, and two of bleeding. All of these were controlled by means of haemostatic suturing. In relation to postoperative complications, the most common of these were as follows: transitory tenesmus (21.4%); pain (7.2%); mucosal or haemorrhoidal prolapse (6.4%); residual skin tag (5.6%); faecal impaction (3.2%); haemorrhoidal thrombosis (2.8%); bleeding (2.1%); anal fissure (0.7%); and anal abscess (0.3%). Most of the complications were treated conservatively, and only 7.5% (53/705) required some type of surgical approach. There was no mortality or any severe complications. The recurrence of prolapse and bleeding was greater in patients with grade IV haemorrhoidal disease than in those with grade III and II (26.54% and 7.96% vs. 2.31% and 0.92% vs. 2.5% and 1.25%), respectively.

Conclusion:

The THD-M method is safe and effective for haemorrhoidal disease grades II and III with low rates of surgical complications. However, for grade IV hemorrhoids, it is associated with higher recurrence of prolapse and bleeding. So, THD-M method should not be considered as an effective option for the treatment of grade IV hemorrhoids.

Outcomes of a modified Bresler procedure for the treatment of rectocele with rectal intussusception

Background

Obstructed defecation syndrome (ODS) is a condition that is frequently caused by rectocele and rectal intussusception. This study aimed to evaluate the effectiveness of a modified Bresler procedure for the treatment of ODS. The outcomes of this modified procedure were compared with the stapled transanal rectal resection (STARR) procedure.

Methods

We performed a retrospective analysis of the clinical data from 76 female patients who presented with ODS between June 2014 and June 2016. The patients were divided into two treatment groups, namely Modified and STARR. Patients in the Modified group (n = 36) underwent the modified Bresler procedure, which involved posterior rectal-wall resection using a circular tubular stapler with multilevel purse-string sutures. Patients in the STARR group (n = 40) underwent the standard STARR procedure. We analysed post-operative complications, Wexner constipation scores (WCS), rectocele depths, and four-point post-operative satisfaction scales.

Results

Patients in the Modified group exhibited shorter operative times and fewer post-operative complications (both P < 0.05). At 12 months post-operatively, both the Modified and STARR groups displayed a significant improvement in the Wexner constipation score and the depth of rectocele. The post-operative WCS for the Modified group were significantly improved compared to those for the STARR group (P < 0.05), while there was no significant difference in the rectocele depth between the two groups (P > 0.05). Post-operative interviews at post-operative 12 months showed that patients in the Modified group had a better satisfaction (P = 0.05).

Conclusions

Our modified procedure may be an effective treatment strategy for patients experiencing ODS caused by rectocele and rectal intussusception, with fewer complications and effective relief of symptoms.

Still a Case of "No Pain, No Gain"? An Updated and Critical Review of the Pathogenesis, Diagnosis, and Management Options for Hemorrhoids in 2020

The treatment of haemorrhoids remains challenging: multiple treatment options supported by heterogeneous evidence are available, but patients rightly demand a tailored approach. Evidence for newer surgical techniques that promise to be less painful has been conflicting. We review the current evidence for management options in patients who present with varying haemorrhoidal grades. A review of the English literature was performed utilizing MEDLINE/PubMed, Embase, and Cochrane databases (31 May 2019). The search terms (haemorrhoid OR haemorrhoid OR haemorrhoids OR haemorrhoids OR “Hemorrhoid”[Mesh]) were used. First- and second-degree haemorrhoids continue to be managed conservatively. The easily repeatable and cost-efficient rubber band ligation is the preferred method to address minor haemorrhoids; long-term outcomes following injection sclerotherapy remain poor. Conventional haemorrhoidectomies (Ferguson/Milligan-Morgan/Ligasure haemorrhoidectomy) still have their role in third- and fourth-degree haemorrhoids, being associated with lowest recurrence; nevertheless, posthaemorrhoidectomy pain is problematic. Stapled haemorrhoidopexy allows quicker recovery, albeit at the costs of higher recurrence rates and potentially serious complications. Transanal Haemorrhoidal Dearterialization has been promoted as nonexcisional and less invasive, but the recent HubBLe trial has questioned its overall place in haemorrhoid management. Novel “walk-in-walk-out” techniques such as radiofrequency ablations or laser treatments will need further evaluation to define their role in modern-day haemorrhoid management. There are numerous treatment options for haemorrhoids, each with their own evidence-base. Newer techniques promise to be less painful, but recurrence rates remain an issue. The balance continues to be sought between long-term efficacy, minimisation of postoperative pain, and preservation of anorectal function.

Mucopexy-Recto Anal Lifting (MuRAL) in managing obstructed defecation syndrome associated with prolapsed hemorrhoids and rectocele: preliminary results

Purpose

Treatment of rectocele associated with prolapsed hemorrhoids is a debated topic. Transanal stapling achieved good midterm results in patients with symptoms of obstructed defecation, nevertheless a number of severe complications have been reported. The aim of this study was to evaluate the safety and efficacy of a new endorectal manual technique in patients with obstructed defecation due to the combination of muco-hemorrhoidal prolapse and rectocele.

Methods

Patients enrolled after preoperative obstructed defecation syndrome (ODS) score, defecography and anoscopy were submitted to the novel Mucopexy-Recto Anal Lifting (MuRAL) combined with a modified Block procedure, and followed up by independent observers with digital exploration 3 weeks postoperatively, and digital exploration plus anoscopy at 3, 6, and 12 months. Operative time, hospital stay, numerating rating scale (NRS), ODS, satisfaction scores, and recurrence rate were recorded.

Results

Mean operative time was 35.7 minutes. Fifty-six patients completed 1-year follow-up: 7.1% had acute urinary retention, NRS score was < 3 from the third postoperative day, mean time of daily activity resumption was 12 days, none had persistent fecal urgency, 82% declared excellent/good satisfaction score, significant improvement of 6- and 12-month ODS score, no recurrence of rectocele, and 7.1% recurrence of prolapsed hemorrhoids were observed.

Conclusion

MuRAL associated with modified Block technique gave no severe complications and resulted in a safe and effective approach to symptomatic rectocele associated with muco-rectal prolapse. Further randomized studies, larger series, and longer follow-up are needed.

Functional outcome and quality of life evaluation of graciloplasty for the treatment of complex recto-vaginal and recto-urethral fistulas

Recto-vaginal (RVF) and recto-urethral (RUF) fistulas are infrequent but disabling conditions that severely affect patients' quality of life. Considering the high recurrence rate after conservative approaches, the best surgical treatment is still challenging. The aim of this study was to evaluate the outcome of graciloplasty to treat patients with complex RVF or RUF, and to investigate its effect on the quality of life. Fourteen patients with RVF and RUF who underwent graciloplasty between 2003 and 2017 were retrospectively enrolled. The main outcome was the healing rate of fistulas. Postoperative patients satisfaction was evaluated administering the Clinical Patient Grading Assessment Scale (CPGAS), SF-36 questionnaires and Changes in Sexual Functioning (CSF) questionnaires. The Wexner score was calculated in case of preoperative faecal incontinence. RVF and RUF were iatrogenic in 11 patients and due to Crohn's disease in 3 cases. After 1 year of follow-up (IQR 10-14 months), the success rate of the procedure was 78%. Out of three patients with RVF due to Crohn's disease, two healed after the procedure. Six months after surgery, all eight SF-36 domains significantly improved except for "body pain"; CSF score significantly increased from 35.5 (IQR 31-38.7) to 44 (IQR 37.7-48.5); CPGAS score improved from a median value of 0 (IQR 0-0) to 4 (IQR 3.2-4). The Wexner score was calculated only in 5 patients with preoperative faecal incontinence and it significantly decreased from a median value of 12 (IQR 11-14) to 5 (IQR 4-5). Graciloplasty could be considered as a first option treatment for complex or recurrent RVF and RUF. It shows a good healing rate even in case of unfavourable factors like Crohn's disease.

Consensus statement of the Italian society of colorectal surgery (SICCR): management and treatment of hemorrhoidal disease

Hemorrhoidal disease (HD) is the most common proctological disease in the Western countries. However, its real prevalence is underestimated due to the frequent self-medication.The aim of this consensus statement is to provide evidence-based data to allow an individualized and appropriate management and treatment of HD. The strategy used to search for evidence was based on application of electronic sources such as MEDLINE, PubMed, Cochrane Review Library, CINAHL, and EMBASE.These guidelines are inclusive and not prescriptive.The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by American College of Chest Physicians. The recommendations were graded A, B, and C.

Khubchandani’s procedure combined with stapled posterior rectal wall resection for rectocele

BACKGROUND

Obstructed defecation syndrome (ODS) is a widespread disease in the world. Rectocele is the most common cause of ODS in females. Multiple procedures have been performed to treat rectocele and no procedure has been accepted as the gold-standard procedure. Stapled transanal rectal resection (STARR) has been widely used. However, there are still some disadvantages in this procedure and its effectiveness in anterior wall repair is doubtful. Therefore, new procedures are expected to further improve the treatment of rectocele.

AIM

To evaluate the efficacy and safety of a novel rectocele repair combining Khubchandani’s procedure with stapled posterior rectal wall resection.

METHODS

A cohort of 93 patients were recruited in our randomized clinical trial and were divided into two different groups in a randomized manner. Forty-two patients (group A) underwent Khubchandani’s procedure with stapled posterior rectal wall resection and 51 patients (group B) underwent the STARR procedure. Follow-up was performed at 1, 3, 6, and 12 mo after the operation. Preoperative and postoperative ODS scores and depth of rectocele, postoperative complications, blood loss, and hospital stay of each patient were documented. All data were analyzed statistically to evaluate the efficiency and safety of our procedure.

RESULTS

In group A, 42 patients underwent Khubchandani’s procedure with stapled posterior rectal wall resection and 34 were followed until the final analysis. In group B, 51 patients underwent the STARR procedure and 37 were followed until the final analysis. Mean operative duration was 41.47 ± 6.43 min (group A) vs 39.24 ± 6.53 min (group B). Mean hospital stay was 3.15 ± 0.70 d (group A) vs 3.14 ± 0.54 d (group B). Mean blood loss was 10.91 ± 2.52 mL (group A) vs 10.14 ± 1.86 mL (group B). Mean ODS score in group A declined from 16.50 ± 2.06 before operation to 5.06 ± 1.07 one year after the operation, whereas in group B it was 17.11 ± 2.57 before operation and 6.03 ± 2.63 one year after the operation. Mean depth of rectocele decreased from 4.32 ± 0.96 cm (group A) vs 4.18 ± 0.95 cm (group B) preoperatively to 1.19 ± 0.43 cm (group A) vs 1.54 ± 0.82 cm (group B) one year after operation. No other serious complications, such as rectovaginal fistula, perianal sepsis, or deaths, were recorded. After 12 mo of follow-up, 30 patients’ (30/34, 88.2%) final outcomes were judged as effective and 4 (4/34, 11.8%) as moderate in group A, whereas in group B, 30 (30/37, 81.1%) patients’ outcomes were judged as effective, 5 (5/37, 13.5%) as moderate, and 2 (2/37, 5.4%) as poor.

CONCLUSION

Khubchandani’s procedure combined with stapled posterior rectal wall resection is an effective, feasible, and safe procedure with minor trauma to rectocele.

Stapled transanal rectal resection for the treatment of rectocele associated with obstructed defecation syndrome: a large series of 262 consecutive patients

BACKGROUND

This study aims to investigate functional results and recurrence rate after stapled transanal rectal resection (STARR) for rectocele associated with obstructive defection syndrome (ODS).

METHODS

A study was conducted on patients with ODS symptoms associated with symptomatic rectocele ≥ 3 cm on dynamic defecography who had STARR at our institution between 01/2007 and 12/2015. Data were prospectively collected and analyzed. ODS was evaluated using the Wexner constipation score. Primary outcomes were functional results, determined by the improvement in 6-month postoperative Wexner constipation score, and 1-year recurrence. Secondary outcomes were operative time, time to return to work, pain intensity measured using the visual analogue scale (VAS), patient satisfaction, and overall postoperative morbidity and mortality at 30 days.

RESULTS

Two-hundred-sixty-two consecutive female patients [median age 54 years (range 20-78)] were enrolled in the study. The median duration of follow-up was 79 months (range 30-138). Sixty (23%) patients experienced postoperative complications, but only 9 patients required reinterventions for surgical hemostasis (n = 7), fecal diversion for anastomotic leakage (n = 1), and recto-vaginal fistula repair (n = 1). Only 1 intraoperative complication (stapler misfire) was reported, and there were no deaths. There was a statistically significant (p < 0.001) reduction in the median (range) Wexner constipation score from 19 (14-24) preoperatively to 9 (5-15) 6 months postoperatively. Only 10 (4%) patients experienced recurrence and only 3 of them required additional reintervention. Patient satisfaction at 1 year was excellent in 86%, good in 13%, and poor in 1% of patients.

CONCLUSIONS

STARR is a safe, effective, and minimally invasive technique for the treatment of rectocele associated with ODS.

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.

Standard stapled transanal rectal resection versus stapled transanal rectal resection with one high-volume stapler to prevent complications in the elderly

BACKGROUND

The causes of obstructed defecation syndrome (ODS) can actually be either functional or mechanical (primary or secondary deficit of the sensitivity, slow bowel transit, pelvic floor dyssynergia, internal and external rectal prolapse, recto-anal intussusceptions, anterior or posterior rectocele and pelvic prolapse of the bladder, uterus, bowel or sigma). The aim of our study was to evaluate the safety, efficacy and feasibility of stapled transanal rectal resection (STARR) procedure performed by a single or double stapler through clinical and functional outcomes for transanal stapled surgery.

METHODS

From January 2016 to October 2017, ninety patients with ODS secondary to rectal prolapse, anal-rectal intussusception and anterior rectocele, that underwent to a STARR procedure were enrolled. Thirty of these underwent a STARR procedure with double circular stapler PPH-01 (Group A); 30 with single circular stapler CPH34HV with a purse string suture (Group B); and 30 with single circular stapler CPH34HV with a "parachute technique" (Group C). All patients were selected with clinical examination, Wexner score for fecal incontinence and ODS score for constipation. Patients also underwent a Defeco RMN for an anatomical and dynamic evaluation of the pelvic floor.

RESULTS

No recurrence rates were observed in the three groups. The mean operative time was 46.3 minutes in group A; 34.5 minutes in group B; and 37.6 minutes in Group C. The volume of the resected specimen was 17 mL in group A; 15 mL in group B; and 16 mL in Group C. Complications were bleeding (3.3% in group A); fecal urgency (6.6% in group A, 10% in group B and 3.3% in group C); rectal hematoma (3.3% in group A). all symptoms significantly improved after the operation without differences between groups.

CONCLUSIONS

The STARR technique performed with a single stapler CPH34HV is safe, faster and less expensive than the STARR performed by a double PPH01. Besides, with the parachute technique, it is possible to resect asymmetric prolapses.

Laparoscopic Ventral Rectopexy Versus Stapled Transanal Rectal Resection for Treatment of Obstructed Defecation in the Elderly: Long-term Results of a Prospective Randomized Study

BACKGROUND

Obstructed defecation is a common complaint in coloproctology. Many anal, abdominal, and laparoscopic procedures are adopted to correct the underlying condition.

OBJECTIVE

The purpose of this study was to compare long-term functional outcome, recurrence rate, and quality of life between laparoscopic ventral rectopexy and stapled transanal rectal resection in the treatment of obstructed defecation.

DESIGN

This was a prospective randomized study.

SETTING

This study was performed at academic medical centers.

PATIENTS

Patients were included if they had obstructed defecation attributed to pelvic structural abnormalities that did not to respond to conservative measures. Exclusion criteria included nonrelaxing puborectalis, previous abdominal surgery, other anal pathology, and pudendal neuropathy.

INTERVENTION

Patients were randomly allocated to either laparoscopic ventral rectopexy (group 1) or stapled transanal rectal resection (group 2).

MAIN OUTCOME MEASURES

The primary outcome measures were improvement of modified obstructed defecation score and recurrences after ≥3 years of follow-up. Secondary outcomes were postoperative complications, continence status using Wexner incontinence score, and quality of life using Patient Assessment of Constipation-Quality of Life Questionnaire.

RESULTS

The study included 112 patients (56 in each arm). ASA score II was reported in 32 patients (18 in group 1 and 14 in group 2; p = 0.12), whereas 3 patients in each group had ASA score III. Minor postoperative complications were seen in 11 patients (20%) of group 1 and 14 patients of group 2 (25%; p = 0.65). During follow-up, 3 patients had fecal urgency after stapled transanal rectal resection but no sexual dysfunction in either procedure. After 6 months, modified obstructed defecation score improvement >50% was reported in 73% versus 82% in groups 1 and 2 (p = 0.36). After a mean follow-up of 41 months, recurrences of symptoms were reported in 7% in group 1 versus 24% in group 2 (p = 0.04). Six months postoperation, perineal descent improved >50% in defecogram in 80% of group 1 versus no improvement in group 2. Quality of life significantly improved in both groups after 6 months; however a significant long-term drop (>36 months) was seen only in group 2.

LIMITATIONS

Possible limitations of this study are the presence of a single operator and the absence of blindness of the technique for both patient and assessor.

CONCLUSIONS

In elderly patients even with comorbidities, both laparoscopic ventral rectopexy and stapled transanal rectal resection are safe and can improve function of the anorectum in patients with obstructed defecation attributed to structural abnormalities. Laparoscopic ventral rectopexy has better long-term functional outcome, less complications, and less recurrences compared with stapled transanal rectal resection. Perineal descent only improves after laparoscopic ventral rectopexy. Stapled transanal rectal resection was shown not to be the first choice in elderly patients with obstructed defecation unless they had a medical contraindication to laparoscopic procedures. See Video Abstract at http://links.lww.com/DCR/A788.

Transanal hemorrhoidal dearterialization (THD) versus stapled hemorrhoidopexy (SH) in treatment of internal hemorrhoids: a systematic review and meta-analysis of randomized clinical trials

BACKGROUND

Although conventional hemorrhoidectomy proved effective in treatment of hemorrhoidal disease, postoperative pain remains a vexing problem. Alternatives to conventional hemorrhoidectomy as transanal hemorrhoidal dearterialization (THD) and stapled hemorrhoidopexy (SH) were described. The present meta-analysis aimed to review the randomized trials that compared THD and SH to determine which technique is superior in terms of recurrence of hemorrhoids, complications, and postoperative pain.

METHODS

Electronic databases were searched for randomized trials that compared THD and SH for internal hemorrhoids. The PRISMA guidelines were followed when reporting this meta-analysis. The primary endpoint of the analysis was persistence or recurrence of hemorrhoidal disease. Secondary endpoints were postoperative pain, complications, readmission, return to work, and patients' satisfaction.

RESULTS

Six randomized trials including 554 patients (THD = 280; SH = 274) were included. The mean postoperative pain score of THD was significantly lower than SH (2.9 ± 1.5 versus 3.3 ± 1.6). 13.2% of patients experienced persistent or recurrent hemorrhoids after THD versus 6.9% after SH (OR = 1.93, 95%CI = 1.07-3.51, p = 0.029). Complications were recorded in 17.1% of patients who underwent THD and 23.3% of patients who underwent SH (OR = 0.68, 95%CI 0.43-1.05, p = 0.08). The average duration to return to work after THD was 7.3 ± 5.2 versus 7.7 ± 4.8 days after SH (p = 0.34). Grade IV hemorrhoids was significantly associated with persistence or recurrence of hemorrhoidal disease after both procedures.

CONCLUSION

THD had significantly higher persistence/recurrence rate compared to SH whereas complication and readmission rates, hospital stay, return to work, and patients' satisfaction were similar in both groups.

Surgical management of haemorrhoids: an Italian survey of over 32 000 patients over 17 years

AIM

The management of haemorrhoids has changed significantly in the last two decades as a result of new insights into their pathophysiology and the availability of new surgical devices. The aim of this survey was to evaluate changes in the management of haemorrhoids in Italy over the last 17 years.

METHOD

An electronic database which recorded details of management relating to the severity of haemorrhoids between 2000 and 2016 was obtained from 18 of 34 colorectal surgeons who were invited to participate.

RESULTS

A total of 32 458 patients were treated for haemorrhoids by 18 expert coloproctologists during a 17-year period. Patients were classified as Grade II (7542, 23.2%), Grade III(15 360, 47.3%) and Grade IV (9556, 29.4%). Grade II haemorrhoids were treated with rubber band ligation in over 90% of the cases, and patients with Grade IV had a Milligan-Morgan (MM) haemorrhoidectomy in over 90% of the cases. In Grade III, the use of stapled haemorrhoidopexy progressively decreased from 30% to 35% (between 2000 and 2007) to 5% of the cases. Meanwhile, commencing from 2006 the use of Doppler-guided haemorrhoid artery ligation (DGHAL) with mucopexy increased progressively from 6% to 24%. Over the years, the percentage of MM haemorrhoidectomy remained consistent at between 65% and 70% of the cases.

CONCLUSION

Relevant changes in the surgical choice of haemorrhoid treatment have occurred in Italy over the last 17 years. MM haemorrhoidectomy remains the most frequently performed procedure for Grade III haemorrhoids. Stapled haemorrhoidopexy has become much less popular in contrast to DGHAL with mucopexy which is being performed much more frequently.

Perineal Stapled Rectal Prolapse Resection in Elderly Patients: Long-term Follow-up

BACKGROUND

Full-thickness rectal prolapse has a significant negative impact on quality of life. The therapeutic options, specifically in elderly patients, are imperfect. Perineal stapled rectal prolapse resection is a novel operation for treating external rectal prolapse. Long-term follow-up following this procedure is lacking. In our study, we report a long-term follow-up of 30 patients, analyzing the long-term recurrence rate, morbidity, and functional outcome.

OBJECTIVE

This study aimed to examine the long-term results of perineal stapled rectal resection in a population unfit for prolonged general anesthesia.

DESIGN

This was a cohort study with a prospective follow-up.

SETTINGS

This study was conducted at a single tertiary referral center.

PATIENTS

Patients undergoing perineal stapled rectal resection from January 2010 to June 2013 were included.

INTERVENTIONS

Perineal stapled rectal prolapse resection was performed.

MAIN OUTCOME MEASURES

The primary outcome measured was prolapse recurrence.

RESULTS

A total of 30 patients underwent the surgical intervention. The median follow-up period was 61 months (range, 37-65). No intraoperative or postoperative complications occurred. Six patients (20%) had recurrent rectal prolapse, and continence was not achieved in any of the patients. Two patients who had recurrence underwent a redo perineal stapled rectal resection.

LIMITATIONS

This study was limited by the small cohort of selected patients.

CONCLUSIONS

Frail patients that can only endure a short procedure under regional anesthesia should be considered for perineal stapled rectal prolapse resection. The lack of mortality and morbidity, specifically in this population, along with the low long-term recurrence rates, make this a favorable surgical alternative. See Video Abstract at http://links.lww.com/DCR/A745.

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.

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.

Mucopexy-recto anal lifting: a standardized minimally invasive method of managing symptomatic hemorrhoids, with an innovative suturing technique and the HemorPex System®

BACKGROUND

Conservative surgery of hemorrhoidal disease is less painful than traditional hemorrhoidectomy, and mucopexy has less risk of serious postoperative complications than stapled hemorrhoidopexy. The aim of this study was to evaluate the safety and effectiveness of a standardized, modified hemorrhoidopexy, named Mucopexy-Recto Anal Lifting (MuRAL) with the HemorPex System (HPS) in patients with symptomatic III and IV degree hemorrhoids.

METHODS

Patients were enrolled from May 2013 to Dec 2015 and operated on with the MuRAL technique, based on arterial ligation and mucopexy at 6 locations, using a standardized clockwise/anti-clockwise rotation sequence of the HPS anoscope. Follow-up controls were carried out by independent observers, as follows: a digital exploration 3 weeks after the intervention, digital exploration plus proctoscopy at 3 and 12 months and repeated at a 12 months interval. Patients who did not strictly follow the postoperative controls were excluded from the study. Primary outcome measurement was the recurrence rate. Secondary measurements were: operative time, hospital stay, postoperative pain, postoperative symptoms and satisfaction score.

RESULTS

We operated on 126 patients (72 males, mean age 53.9, range 29-83): 87 (69.6%) with III degree and 39 with IV degree hemorrhoids; 13 patients had a MuRAL as a revisional procedure of a previous operation for hemorrhoids. Mean duration of follow-up was 554 days (range 281-1219). Four patients were excluded from the study. One-year recurrence rate was 4.1%. The mean duration of the intervention was 29.5 minutes (range 23-60) and 92 patients (73%) were discharged during the same day of the operation. Pain VAS Score in the first, second and third postoperative day was 3.9, 2.5, and 1.9, respectively. Twenty-two patients (18%), all submitted to spinal anesthesia, had postoperative acute urinary retention. Fecal urgency, observed in 18.8% of patients at the first control, disappeared within one year after the operation. Mean time to return to normal activity was 8 days (range 5 -10). The patient satisfaction scores at one-year follow up were 31.1% excellent, 57.4% good, 7.4% fairly good and 4.1% poor. In patients with III degree hemorrhoids operative time was significantly shorter, postoperative pain better and transient fecal urgency lower than in IV degree patients. In our experience the standardization of MuRAL operation with HPS, turned out to be a safe and effective minimally invasive approach in managing symptomatic III and IV degree hemorrhoids, avoiding the risk of severe complications, with the possibility to perform a redo-MuRAL in the event of recurrence.

CONCLUSIONS

In our series up to 88% of the patients reported a good, or excellent one-year satisfaction score. Further comparative randomized studies with longer follow-up period are needed.

Procedure for prolapse and hemorrhoids (PPH) with low rectal anastomosis using a PPH 03 stapler: low rate of recurrence and postoperative complications

PURPOSE

The procedure for prolapse and hemorrhoids (PPH) has the advantage of less postoperative pain. However, serious postoperative complications have been reported after PPH, and the postoperative recurrence rate is high in comparison with conventional Milligan-Morgan hemorrhoidectomy (MMH). The purpose of this study was to evaluate PPH with low rectal anastomosis (PPH-LA) in comparison with the original PPH and MMH.

METHODS

Among a total of 1315 patients with hemorrhoids, MMH was conducted in 322, original PPH using a PPH 01 stapler (PPH01) in 63, PPH-LA using 01 (PPH-LA01) in 236, 03 (PPH-LA03) in 649, and sclerotherapy (SCL) in 45.

RESULTS

Length of hospital stay and number of working days lost were significantly greater for MMH than for any form of PPH. The rate of massive postoperative bleeding was significantly lower after PPH-LA03 than after PPH01 or PPH-LA01. No serious postoperative complications occurred after any form of PPH. A significantly higher proportion of patients complained of continued prolapse after PPH01 than after MMH, PPH-LA01, or -LA03. The 5- and 16-year postoperative cumulative recurrence rates after PPH-LA03 were significantly lower than after PPH01.

CONCLUSIONS

The postoperative cumulative recurrence rate after PPH-LA03 is as low as that after MMH for up to 16 years, and compared with the original PPH01, the effectiveness is higher and the postoperative cumulative recurrence rate for up to 16 years is significantly lower. We conclude that PPH-LA03 is a superior procedure for hemorrhoids, having less postoperative pain and a low rate of recurrence.

Postoperative MR Defecography following Failed STARR Procedure for Obstructive Defecation Syndrome: A Three-Centre Experience

Aim

To describe the abnormalities at MR imaging and related complaints in patients with poor outcome after STARR procedure.

Materials and Methods

The medical records of 21 symptomatic patients from centre 1, 31 patients from centre 2, and 63 patients from centre 3 were reviewed with regard to findings at MR defecography and related symptoms.

Results

Regardless of the centre, most relevant imaging features and related complaints were (a) impaired emptying (82.11%), related complaint ODS; (b) persistent rectocele >2 cm and intussusception (39.3%), split evacuation and digitation; (c) pelvic organ descent on straining (39.8%), prolapse sensation; (d) small neorectum and loss of contrast (32.5%), urgency and incontinence; (e) anastomotic stricture and granuloma (28.4%), pain; and (f) nonrelaxing puborectalis muscle (19.5%), tenesmus. Less frequent findings included rectal pocket formation (5.6%) and rectovaginal sinus tract (1.6%). Patients were referred to MR imaging with an average time interval of 5 ± 2, 4 ± 1, and 2 ± 1 years in the three centres, respectively, and only rarely by the same surgeon who performed the operation: 1/21 (4.8%) in centre 1, 3/39 (7.7%) in centre 2, and 9/63 (14.3%) in centre 3.

Conclusion

Most surgeons involved in STARR operation with subsequent poor outcome do not rely on MR imaging.

A Randomized Multicenter Clinical Trial of RPH With the Simplified Milligan-Morgan Hemorrhoidectomy in the Treatment of Mixed Hemorrhoids

PURPOSE

To explore the safety and efficacy of Ruiyun procedure for hemorrhoids (RPH) or RPH with the simplified Milligan-Morgan hemorrhoidectomy (sMMH) in the treatment of mixed hemorrhoids.

METHODS

This is a randomized, controlled, balanced, multicenter study of 3000 patients with mixed hemorrhoids. The outcomes and postoperative complications were compared between 5 types of surgeries.

RESULTS

The efficacy rate was the highest in patients who received RPH+sMMH and decreased in the following order: patients who received RPH alone, MMH alone, procedure for prolapse and hemorrhoids (PPH) alone, and PPH+sMMH ( P < .05). The operation time was the shortest in patients who received RPH alone and increased in the following order: patients who received RPH+sMMH, PPH alone, MMH alone, and PPH+sMMH ( P < .01). The duration of postoperative hospitalization stay was the shortest in patients who received RPH alone and increased in the following order: PPH alone, RPH+sMMH, PPH+sMMH, and MMH alone ( P < .01). The incidence of postoperative hemorrhage, uroschesis, anal fissure, crissum hematoma or thrombosis, and anorectal stenosis was significantly lower in patients who received RPH+sMMH than in patients who received the other 4 types of surgical treatments ( P < .05, P < .01). No significant differences in postoperative rectovaginal fistula and anal incontinence were observed between the 5 groups of patients.

CONCLUSIONS

RPH with or without simplified MMH can reduce the incidence of postoperative complications and improve the curative efficacy in the treatment of patients with mixed hemorrhoids.

Value and limits of stapled transanal rectal repair for obstructed defecation syndrome: 10 years-experience with 450 cases

BACKGROUND/OBJECTIVE

In the late's 90' a new surgical treatment, the stapled trans-anal rectal resection (STARR) was born to treat obstructed defecation syndrome (ODS). In this study we retrospectively analyze a series of 450 cases that underwent STARR in 10 years.

METHODS

Between January 2001 to December 2011, 450 patients, diagnosed with ODS syndrome caused by rectocele or intussusception, underwent to STARR procedure. The presence of rectocele and/or intussusception was verified by dynamic defecography. The preoperative evaluation was completed with anorectal manometry and colonoscopy. Follow-up visits were scheduled 1 week, 1 month, 3 months, 1 years, 3 years and 5 years after surgery.

RESULTS

Mean operative time was 30,2 min. In 408 cases (90.7%) hospital discharge occurred 24 hours after surgery. Among postoperative complications urinary retention was observed in 35 patients (7.8%). Five (1.1%) patients presented an early rectal bleeding and 8 (1.8%) patients presented a late bleeding. In 5 (1.1%) patients a stable pelvic hematoma was found. Six (1.3%) patients presented pelvic sepsis due to subperitoneal perforation. An asymptomatic partial dehiscence of stapler row occurred in 19 patients (4.2%).125 patients (27.8%) reported defecation urgency that completely vanished at 3 months follow-up in 83 patients (66,4%) and in further 42 patients (33,6%) at 6-months. The average preoperative ODS score was 14.1; 3.1 at one year; 4.3 at 3 years and 6.4 after five years.

CONCLUSIONS

In expert hands, with right indications, STARR procedure is safe with good results in terms of improvement of the ODS score.