The tissue selecting technique (TST) versus the Milligan–Morgan hemorrhoidectomy for prolapsing hemorrhoids: a retrospective case–control study

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.

Prevention and Treatment of Anastomotic Strictures After Procedure for Prolapse and Hemorrhoids

Procedure for Prolapse and Hemorrhoids (PPH), also known as circular stapled hemorrhoidectomy, is a common method of treating hemorrhoids due to its low risk of complications and minimal postoperative pain. Several complications have appeared alongside the rise of treated cases, however, and this has led to a progressive slowing of the clinical use of PPH in recent years. Anastomotic stenosis is one of the most common complications of PPH, but the greater amount of tissue removed and the speed with which it can heal make it the best choice for patients with severe prolapsed annular hemorrhoids or rectal mucosal prolapse. Therefore, academics continue to comprehensively study PPH to take advantage of annular resection and reduce complications. In this paper, we analyzed the causes, intraoperative warnings, and postoperative therapy of anastomotic stenosis induced by PPH, with an eye toward scientific application in the anorectal field, based on the experience of clinical applications.

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.

Outcome of a modified Park's submucosal hemorrhoidectomy versus Milligan-Morgan for grade III-IV circumferential prolapsed hemorrhoids

BACKGROUND

This prospective randomized controlled study compared the short- and long-term efficacy and advantages of modified Park's submucosal over Milligan-Morgan hemorrhoidectomy (MMH) in the treatment of grade III and IV circumferential prolapsed hemorrhoids (CPH).

METHODS

A total of 186 consecutive patients with grade III or IV CPH were enrolled. The patients were randomized to MPSH (n = 93) or MMH (n = 93) treatment groups. Patient data included demographics, clinical characteristics, surgical parameters, underlying or arising complications, and CPH recurrence. The patients were closely followed up for at least 24 months.

RESULTS

The patient demographic data and clinical parameters were comparable in the two groups (P > 0.05). MPSH took significantly longer operative time (P < 0.05). Although there was no significant difference in mean postoperative pain between the two groups at days 3 and 14, pain at day 7 was significantly more frequent and severe in the MMH group (P < 0.05). There were no significant group differences in postoperative bleeding, intraoperative blood loss, or development of anal stenosis (P > 0.05). However, the cumulative relapse-free rate was substantially higher in the MPSH group (P < 0.05).

CONCLUSION

MPSH and MMH are both practical and safe techniques for treating grade III and IV CPH disease. However, MPSH is safer, easier, and faster to perform and is associated with fewer recurrences within 24 months of surgery. Additional clinical studies are needed to validate these conclusions.

Network meta-analysis of randomized controlled trials comparing the procedure for prolapse and hemorrhoids, Milligan-Morgan hemorrhoidectomy and tissue-selecting therapy stapler in the treatment of grade III and IV internal hemorrhoids(Meta-analysis)

BACKGROUND

Hemorrhoids are one of the most common conditions in the world, and grade III and IV internal hemorrhoids are mainly treated with surgery. However, there are many different surgical methods, and many postoperative complications occur. Therefore, we aimed to update and expand our previous work to compare the safety and efficacy of the procedure for prolapse and hemorrhoids (PPH), Milligan-Morgan hemorrhoidectomy (MMH) and tissue-selecting therapy stapler (TST) in the treatment of grade III and IV internal hemorrhoids.

METHODS

We performed a network meta-analysis. We searched the Cochrane library, Embase, PubMed, Medline, Web of Science, CNKI, Wangfang, and VIP databases up to May 20, 2019. All randomized controlled trials (RCTs) comparing PPH, MMH and TST in the treatment of grade III and IV internal hemorrhoids were included. We performed a Bayesian network meta-analysis to integrate the adverse events of all treatments. This work is reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and Assessing the Methodological Quality of Systematic Reviews (AMSTAR) guidelines. This study was registered with PROSPERO, number CRD42019137270.

RESULT

Twenty-two RCTs that recruited 3511 patients were identified. Among these patients, 1379 patients underwent PPH, 805 patients underwent TST, and 1327 patients underwent MMH. In terms of adverse events, TST presented the lowest urinary retention rates and fecal incontinence rates. TST exhibited fewer incidences of anal stenosis than PPH and MMH. Importantly, PPH showed the weakest effects on reducing recurrence rates in hemorrhoid patients.

CONCLUSIONS

The current study indicated that TST showed optimal potential superior clinical effects for grade III and IV hemorrhoids compared to PPH and MMH. However, high-quality large sample RCTs are still expected.

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.

Effects of Topical Atorvastatin (2 %) on Posthemorrhoidectomy Pain and Wound Healing: A Randomized Double-Blind Placebo-Controlled Clinical Trial

BACKGROUND

Atorvastatin is a 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase inhibitor widely used in treatment of hypercholesterolemia and prevention of coronary heart disease and has various pleiotropic effects. In this study, the efficacy of atorvastatin emulgel (2 %) in reducing postoperative pain at rest, pain during defecation and analgesic requirement after open hemorrhoidectomy was investigated.

METHODS

A total of 66 patients with third- and fourth-degree hemorrhoids undergoing open hemorrhoidectomy were included in this prospective, double-blind, randomized controlled trial. The patients were randomly assigned to either atorvastatin emulgel or placebo immediately after surgery and then every 12 h for 14 days. The primary outcomes were intensity of pain at rest and during defecation, measured with a visual analog scale, and the analgesic requirement, measured by amount of pethidine and acetaminophen consumption, and percent of wound healing.

RESULTS

There was no significant difference in the average postoperative pain scores in the first 48 h (P _12h = 1, P _24h = 0.128 and P _48h = 0.079) after the surgery between the two groups, but at the week 1 the pain scores during defecation were considerably lower in the atorvastatin group than in placebo group (P = 0.004), which also was the same at the week 2 (P = 0.03). There was no significant difference in the average pethidine and acetaminophen (mg) administration at 12 h and 24 h between the two groups after surgery. Regarding the data about wound healing, at the week two the healing was much better in the treatment group than it was in control group and the difference was statistically significant (P = 0.04).

CONCLUSIONS

Compared with placebo, atorvastatin emulgel reduced postoperative pain at rest and on defecation and could improve the healing process after open hemorrhoidectomy.

TRIAL REGISTRATION NUMBER

IRCT201404013014N8.

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

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

Early Experience With a Partial Stapled Hemorrhoidopexy for Treating Patients With Grades III-IV Prolapsing Hemorrhoids

PURPOSE

Circular stapled hemorrhoidopexy (CSH) is widely used to treat patients with grades III-IV hemorrhoids because of less pain and short hospital stay. However, this procedure is associated with some complications, such as urge to defecate, anal stenosis, staple line dehiscence, abscess and sepsis. To avoid these complications, surgeons perform a partial stapled hemorrhoidopexy (PSH). The aim of this study is to present our early experience with the PSH.

METHODS

We retrospectively reviewed the medical records of 58 patients with hemorrhoids who were treated with a PSH at Busan Hang-Un Hospital from January 2016 to June 2016. A specially designed tri-window anoscope was used, and a purse string suture was made at the mucosae of the protruding hemorrhoids through the window of the anoscope. The hemorrhoidopexy was done by using a circular stapler.

RESULTS

Of the 58 patients included in this study, 34 were male and 24 were female patients (mean age, 50.4 years). The mean operation time was 12.4 minutes, and the mean postoperative hospital stay was 3.8 days. Three patients experienced bleeding (5.1%) 5 urinary retention (8.6%) and 5 skin tags (8.6%). Urge to defecate, tenesmus, abscess, rectovaginal fistula, anal stricture, incontinence, and recurrence did not occur.

CONCLUSION

PSH is a minimally invasive, feasible, and safe technique for treating patients with grades III-IV hemorrhoids. A PSH, instead of a CSH, can be used to treat certain patients with hemorrhoids.