Complications after stapled hemorrhoidectomy: can they be prevented?

The comparison of doppler-guided haemorrhoidal artery ligation and the tissue selecting technique for patients with grade III/IV haemorrhoids: a retrospective cohort study

This study aimed to evaluate the efficacy and the safety of Doppler-guided hemorrhoid artery ligation (DG-HAL) and tissue-selecting technique (TST) in patients with grade III/IV hemorrhoids. We conducted a retrospective analysis of 251 patients with grade III/IV hemorrhoids between January 2019 and January 2021. Among them, 119 patients had received TST, and the remaining 132 patients received DG-HAL. We collected and compared clinical characteristics of both groups, including post-operative visual analog scale (VAS) for pain, post-operative bleeding, post-operative defecation, urinary retention, and recurrence rate (prolapse and bleeding). The VAS pain score of the first post-operative defecation and at the post-operative day (POD)1 and 2 for the DG-HAL group was lower than those for the TST group (P = 0.006 and P = 0.029). The incidence of post-operative complications (including bleeding, urinary retention and sensation of rectal tenesmus) in the DG-HAL group was lower than that in the TST group (P = 0.021, P = 0.035 and P = 0.047). At follow-up by telephone or outpatient 3 years after surgery, the recurrence rate (prolapse) was lower in the TST group than in the DG-HAL group (P = 0.013). Subgroup analysis showed a higher prolapse recurrence rate in grade IV patients than grade III patients after DG-HAL (P = 0.013). DG-HAL had fewer complications, lower bleeding rates, and less early post-operative pain but showed a higher recurrence rate than TST at the 3-year follow-up, especially in grade IV patients.

A comparative study on efficacy and safety of modified partial stapled hemorrhoidopexy versus conventional hemorrhoidectomy: a prospective randomized controlled trial

PURPOSE

The long-term outcomes and efficacy of partial stapled hemorrhoidopexy (PSH) compared with those of conventional hemorrhoidectomy (CH) are not fully understood. This study aimed to introduce a modified PSH (mPSH) and compare its clinical efficacy and safety with those of CH.

METHODS

A prospective randomized controlled trial was conducted. This study was performed at a single hospital and involved 6 colorectal surgeons. In total, 110 patients were enrolled between July 2019 and September 2020. Patients were randomly assigned to undergo either mPSH group (n=55) or CH group (n=55). The primary outcome was to compare postoperative average pain and postoperative peak pain using visual analog scale score between the 2 groups.

RESULTS

The required duration of analgesia was shorter in the mPSH group than in the CH group, although the difference was not statistically significant (P=0.096). However, the laxative requirement duration (P<0.010), return to work (P<0.010), satisfaction score (P<0.010), and Vaizey score (P=0.014) were significantly better in the mPSH group. The average and peak postoperative pain scores were significantly lower in the mPSH group during the 15 days after surgery (P<0.001). The overall complication rate in both groups was 9.1%, with no significant difference between the groups (P=0.867).

CONCLUSION

The mPSH group demonstrated better improvement in symptoms, lower pain scores, and greater patient early satisfaction after surgery than the CH group. Therefore, this surgical technique appears to be a safe and effective alternative for CH.

Propensity-Score Matching Analysis for Laser Hemorrhoidoplasty Versus Circumferential Stapler Hemorrhoidectomy: One-Year Outcomes

BACKGROUND

Laser hemorrhoidectomy (LHP) is a minimally invasive procedure with less pain, short operative time and length of stay, and a low recurrent rate. This study aimed to analyze the surgical outcomes of the circumferential stapler hemorrhoidectomy (CSH, Longo operation) by propensity score-matching analysis, including perioperative outcomes and quality of life.

MATERIALS AND METHODS

Between March 2022 and March 2023, 216 patients underwent CSH and 198 LHP in Binh Dan Hospital, Ho Chi Minh City, Vietnam. Potential confounding factors for operative outcomes were adjusted by propensity score-matching analysis. The gender, age, Goligher classification, symptoms, Hemorrhoidal Disease Symptom Score (HDSS), and the number of hemorrhoidal columns were matching variables. After 1:1 propensity score-matching, 115 patients from each group were evaluated for perioperative outcomes and compared for a prospective study.

RESULTS

There was no difference in potential preoperative confounders such as gender, hemorrhoid classification, symptoms, and HDSS between the two groups after propensity score-matching. However, there was a difference in age (52 in the Longo group and 43 in the LHP group) and the number of columns (the LHP group had more). Postoperative outcomes such as operative time, blood loss, general complications, and postoperative interventions were less in the LHP group. However, Visual Analog Scale (VAS) (4 vs. 4), length of stay (1 day vs. 1 day), quality of life (both groups improved quality of life after the procedure), and recurrence rate (2 in the Longo group vs. 0 in the LHP group, p=0.5) had no difference between the two groups.

CONCLUSIONS

Propensity-score matching analysis showed that the LHP procedure was superior to the Longo operation (CSH) in operative time, blood loss, general complications, and postoperative intervention. Other outcomes such as VAS, length of stay, quality of life, and recurrence rate have no difference.

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.

Ten-year multicentric retrospective analysis regarding postoperative complications and impact of comorbidities in hemorrhoidal surgery with literature review

BACKGROUND

Hemorrhoidal disease (HD) is considered a low-severity pathology by both general population and physicians, but the lengthy conservative therapy and postoperative complications suggest otherwise.

AIM

To assess the effectiveness of different treatment options, both conservative and surgical, in contrast with some preexisting comorbidities.

METHODS

We conducted a retrospective, 10-yearlong study between January 2011 and December 2021 in two surgical centers, a private and a state-owned hospital. We compared the efficacy and safety of several treatment options, such as open hemorrhoidectomy, stapled hemorrhoidopexy, rubber band ligation and infrared coagulation in terms of complication rates and types and their correlation with different preexisting comorbidities such as inflammatory bowel disease (IBD), use of anticoagulant medication (AM) and liver cirrhosis. We also conducted a 20-years long PubMed research (1.263 articles) for relevant comparisons.

RESULTS

Our study recorded 10940 patients with HD, 10241 with conservative and 699 with surgical treatment. Out of these, the male-to-female ratio of 1.3, and a peak in age distribution between 59 and 68 years old (32% of patients). For the entire study, we recorded a 90% incidence of immediate pain, immediate bleeding in 1.5% (11 cases), delayed bleeding in 1.0% (7 cases), and 0.6% surgical site infections. Urinary retention was also present, with 0.2% of patients, anal stricture in 1% and fecal incontinence for 0.5% of patients (4 cases). We recorded no severe complications such as Fournier`s gangrene or rectovaginal perforations. IBD accounted for 6% of the patients, with ulcerative colitis in 12% and Chron`s disease in 10.5%. 6.6% of the patients had AM, determining 4% immediate and 2% delayed bleeding, in surgically treated patients.

CONCLUSION

Our study determined that most common complications (pain, urinary retention, bleeding, and stricture) are correlated with each surgical technique and pre-existing comorbidities.

Self-Mechanical Anal Dilatation: A Simple Trick to Minimize Postoperative Pain and Stenosis Following Hemorrhoidectomy With Radiofrequency

Aim: Hemorrhoidectomy is still the most effective surgical treatment for hemorrhoidal disease, but it is, however, associated with complications such as pain and stenosis. We proposed to break the “vicious circle” of “pain–sphincteric spasm–stenosis–pain” with the postoperative use of self-mechanical anal dilation.

Methods: We retrospectively analyzed patients with hemorrhoidal disease presenting with a minimum of piles of three quadrants, treated with radiofrequency hemorrhoidectomy between January 2018 and December 2019. All the patients that at 3 weeks presented sphincteric spasms with painful defecation, were considered. Thirty-nine patients performed the cycle of self-mechanical anal dilation (Group A). This group was 1:1 matched with homogeneous patients from our historical cohort of patients (Group B). The primary endpoint was the pain evaluation, secondary endpoints: WCS, overall satisfaction of the patient, anal sphincter spasm, scarring, and the incidence of postoperative stenosis.

Results: In Group A mean VAS was 3.25 after 14 days of application and 1.15 at the end of the application. In Group B mean VAS was persistently higher, with a mean VAS of 5 (p = 0.000002) and 3.38 (p = 0.0000000000009). In Group A we observed an improvement of symptoms at the end, with a good overall satisfaction (Group A 7.4 vs. Group B 5.9; p = 0.0000007) and a better mean WCS (Group A WCS 2.8 vs. Group B WCS 4.18; p = 0.0001). Stenosis was observed in 3/39 patients of Group B (7.7%).

Conclusions: Self-mechanical anal dilation improves the pain in the late postoperative course, minimizing the risk of anal stenosis.

Clinical study of use of large C suture in procedure for prolapse and hemorrhoids for treatment of mixed hemorrhoids

OBJECTIVE

To investigate the clinical use of a large C suture in the procedure for prolapse and hemorrhoids (PPH) for treatment of mixed hemorrhoids.

METHODS

Patients with mixed hemorrhoids (grade III or IV) who underwent treatment with a large C suture during PPH in the Affiliated Hospital (Group) of Putian University from 1 April 2018 to 31 March 2019 were enrolled in this retrospective study. The incidences of anastomotic stenosis and anastomotic hemorrhage after the operation were observed.

RESULTS

The study population comprised 126 patients (46 men and 80 women) ranging in age from 30 to 78 years (mean, 46.1 ± 2.5 years). Of these patients, 60 had circular mixed hemorrhoids, 36 had grade III circular internal hemorrhoids, and 30 had grade IV circular internal hemorrhoids. The onset time among all patients ranged from 0.5 to 25 years. All patients underwent 6 months of postoperative follow-up. None of the patients with mixed hemorrhoids developed anastomotic stenosis, although two patients developed secondary anastomotic bleeding.

CONCLUSION

Placement of a large C suture during PPH is a reliable technique for treatment of mixed hemorrhoids. It is simple, effective, and applicable and can be helpful for a large number of patients in primary hospitals.

Surgical management of anal stenosis: anoplasty with or without sphincterotomy

Aim Anal stenosis is an uncommon complication of anorectal surgery, mostly resulting from circumferential hemorrhoidectomy or resection of the skin tag in surgical management of chronic anal fissure. The aim of anoplasty is to restore normal function to the anus by dividing the stricture and widening the anal canal. Internal sphincterotomy may cause gas incontinence and if we manage the stenosis without sphincterotomy it could be failed. Could we use anoplasty without sphincterotomy?

Method The patients with anal stenosis were assigned in to two groups. The first group underwent Y-V anoplasty without partial lateral internal sphinctrotomy and the second one underwent Y-V anoplasty with partial lateral internal sphinctrotomy.

Result A total of 25 patients (10 male and 15 female) underwent anoplasty, 14 without partial lateral internal sphincterotomy and 11 patients with partial lateral internal sphincterotomy. The healing rate of stenosis was 91% and 93% in groups undergoing anoplasty without partial lateral internal sphinctrotomy and anoplasty with partial lateral internal sphictrotomy, respectively (p value 0.69). There was no significant change in both groups for post-operative incontinence complaints.

Conclusion The healing rate of anal stenosis was the same in the patients who underwent Y-V anoplasty with or without partial lateral internal sphinctrotomy. There was no significant change in post-operation incontinence between the two groups. Therefore, Y-V anoplasty would be a safe and simple surgical method in selected patients. Partial lateral internal sphinctrotomy procedure has been noticed in individual cases.

Does Proctologic Surgery Really Influence Sexual Behaviors?

INTRODUCTION

The percentage of the heterosexual population that has experienced and regularly has anal intercourse ranges from 20% to 35% in the USA. This practice increases to 95% in certain populations, including lesbian, gay, bisexual, and transgender people. Due to the lack of data in the literature about the effect of proctologic surgery on anal intercourse, this study aimed to assess the impact of this surgery on sexual behavior in both genders.

MATERIALS AND METHODS

From March 2016 to February 2018, an anonymous questionnaire was submitted to all patients aged >18 who had undergone proctologic surgery in one of two surgical units at tertiary referral centers and was assessed independently of gender. The exclusion criteria were incomplete healing and <3 months follow-up.

RESULTS

In total, 929 patients answered the questionnaire in full. The overall prevalence of preoperative anal intercourse was 22.5%. The rate of anal intercourse among men was 16.7%, while among women, it was 28.9%. The overall postoperative rate of anal intercourse was 11.8%. The rate of postoperative anal intercourse among those who regularly engaged in anal intercourse preoperatively was 52.6%, with a 47.4% rate of non-completion (p <0.0001). The experiences reported during intercourse after surgery were mainly pain, stiffness, and partner discomfort.

CONCLUSION

Considering the statistically significant postoperative AI abandonment rate following all types of proctologic surgery, the surgeon has a duty to both treat the disease and to inform the patient about the possible consequences regarding its influence on anal intercourse.

Rektale Endo-SPONGE®-Therapie bei retroperitonealem Hämatom nach komplexer Hämorrhoidektomie

Die zirkuläre Hämorrhoidopexie ist eine häufig angewandte Operationstechnik bei fortgeschrittenem Hämorrhoidalleiden. Trotz der scheinbar technischen Einfachheit kann es in seltenen Fällen zu lebensbedrohlichen Komplikationen kommen. Es wird über den Fall einer Patientin berichtet, die durch eine Blutung aus der Klammernaht nach Hämorrhoidopexie ein retroperitoneales Hämatom mit konsekutiver Perforation der Klammernaht entwickelte. Eine solche Komplikation ist bislang kaum beschrieben worden. Entgegen ähnlicher Fälle konnte auf eine transabdominelle operative Sanierung verzichtet werden. Die perirektale Hämatomhöhle wurde erfolgreich durch die Einlage von rektalen Endo-SPONGEs® therapiert.

Effect of Topical Baclofen 5% on Post-Hemorrhoidectomy Pain: Randomized Double Blind Placebo-Controlled Clinical Trial

BACKGROUND

Baclofen is an agonist for a subtype of gamma-amino butyric acid (GABA-B) receptors and traditionally been used for the systemic treatment of spasticity. Topical application of baclofen has been shown to reduce pain in patients with localized neuropathic pain.

OBJECTIVES

In this study, we investigate the efficacy of baclofen cream (5%) in reducing postoperative pain and analgesic requirement after open hemorrhoidectomy.

DESIGN

The patients were randomly assigned to either baclofen (5%) cream or placebo immediately after surgery and then every 12 h for 14 days.

PATIENTS

A total of 66 patients with third- and fourth-degree hemorrhoids undergoing open hemorrhoidectomy were randomly assigned to this trial.

SETTING

This study was conducted at a single educational hospital.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcomes were intensity of pain, measured with a visual analog scale, and the analgesic requirement, measured by the amount of the acetaminophen consumption.

RESULTS

No significant difference was found in baseline characteristics between the two groups. Postoperative pain score of the baclofen group was significantly lower on week 1 (P = 0.01) and week 2 (P = 0.02) than the placebo group. Similarly, patients in the baclofen group consumed significantly less analgesic medication on week 1 (P = 0.025) and week 2 (P = 0.024) than the control group.

CONCLUSION

Topical application of baclofen effectively relieves pain after hemorrhoidectomy with minimal side effects.

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.

Retained or expelled staples after transanal stapled surgery: this is the problem!

Study objective The aim is to assess the presence and persistence of the agraphes at the level of staple line after transanal stapled surgery.

Methods From April to December 2016 one-hundred-thirteen patients with variable follow-up (6 months–10 years) were randomly selected among all the patients undergone transanal stapled surgery for haemorrhoidal disease or functional disorders such as obstructed defecation syndrome. Only 87 patients agreed to participate this study. All the patients underwent digital exploration, anoscopy and 360° tridimensional transanal ultrasound.

Main results Different types of stapled transanal surgical procedures were performed: 48 transanal rectal resection with high volume device, 24 stapled haemorrhoidopexy, 8 Double Stapled Haemorrhoidopexy, 7 Transtarr. In 41.4% the staple line was not identified with digital examination or anoscopy and 17.2% of patients have some staples partially expelled inside the lumen. 360° tridimensional transanal ultrasound showed a complete staple line at the ano-rectal junction which appears as an interrupted hyperechoic circular layer.

Conclusion The staples after stapled transanal surgery remain at the level of the staple line independently from the device used by the surgeon leading to the necessity of a shared and adequate language, in fact the shed staples need to be considered as expelled instead of retained.

Comparison of clinical outcomes of multi-point umbrella suturing and single purse suturing with two-point traction after procedure for prolapse and hemorrhoids (PPH) surgery

OBJECTIVES

To compare the clinical outcomes of multipoint umbrella suture and single-purse suture with two-point traction after procedure for prolapse and hemorrhoids surgery (PPH) for the treatment of mixed hemorrhoids.

METHODS

Ninety patients were randomly divided into a PPH plus single-purse suture group (Group A) and a PPH plus multipoint umbrella suture (Group B). All operations were performed by an experienced surgeon. Operation time, width of the specimen, hemorrhoids retraction extent, postoperative pain, postoperative bleeding, and length of hospitalization were recorded and compared. Statistical analysis was conducted by t-test and χ2 test.

RESULTS

There were no significant differences in sex, age, course of disease, and degree of prolapse of hemorrhoids between the two groups. The operative time in Group A was significantly shorter than that in Group B (P < 0.05). However, the incidence rates of submucosal hematoma and incomplete hemorrhoid core retraction were significantly lower in Group B (P < 0.05), whereas the width of the specimens in Group B was greater than that in Group A (P < 0.05). There were fewer redundant skin tags in Group B at three months follow-up. No significant difference in postoperative pain, postoperative bleeding, and time of hospital stay (P > 0.05 for all comparisons) was observed.

CONCLUSION

The multipoint umbrella suture showed better clinical outcomes because of its targeted suture according to the extent of hemorrhoid prolapse.

Documented complications of staple hemorrhoidopexy: a systematic review

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

Anorectal emergencies

Anorectal emergencies refer to anorectal disorders presenting with some alarming symptoms such as acute anal pain and bleeding which might require an immediate management. This article deals with the diagnosis and management of common anorectal emergencies such as acutely thrombosed external hemorrhoid, thrombosed or strangulated internal hemorrhoid, bleeding hemorrhoid, bleeding anorectal varices, anal fissure, irreducible or strangulated rectal prolapse, anorectal abscess, perineal necrotizing fasciitis (Fournier gangrene), retained anorectal foreign bodies and obstructing rectal cancer. Sexually transmitted diseases as anorectal non-surgical emergencies and some anorectal emergencies in neonates are also discussed. The last part of this review dedicates to the management of early complications following common anorectal procedures that may present as an emergency including acute urinary retention, bleeding, fecal impaction and anorectal sepsis. Although many of anorectal disorders presenting in an emergency setting are not life-threatening and may be successfully treated in an outpatient clinic, an accurate diagnosis and proper management remains a challenging problem for clinicians. A detailed history taking and a careful physical examination, including digital rectal examination and anoscopy, is essential for correct diagnosis and plan of treatment. In some cases, some imaging examinations, such as endoanal ultrasonography and computerized tomography scan of whole abdomen, are required. If in doubt, the attending physicians should not hesitate to consult an expert e.g., colorectal surgeon about the diagnosis, proper management and appropriate follow-up.

Comparison of a Hemorrhoidectomy With Ultrasonic Scalpel Versus a Conventional Hemorrhoidectomy

Purpose

A variety of instruments, including circular staplers, ultrasonic scalpels, lasers, and bipolar electrothermal devices, are currently used when performing a hemorrhoidectomy. This study compared outcomes between hemorrhoidectomies performed with an ultrasonic scalpel and conventional methods.

Methods

The study was a randomized prospective review of data available between May 2013 and December 2013, involving 50 patients who had undergone a hemorrhoidectomy for grade III or IV internal hemorrhoids. The hemorrhoidal pedicle was coagulated with an ultrasonic device in the ultrasonic scalpel group (n = 25) and sutured with 3-0 vicryl material after excision in the conventional method group (n = 25).

Results

The patients' demographics, clinical characteristics, and lengths of hospital stay were similar in both groups. The mean ages of the conventional and the ultrasonic scalpel groups were, respectively, 20.8 ± 1.6 and 22.4 ± 5.0 years (P = 0.240). In comparison with the conventional method group, the ultrasonic scalpel group had a shorter operation time (P < 0.005), less postoperative pain on the visual analogue scale score (for example, P = 0.211 on postoperative day 1), and less postoperative bleeding (P = 0.034). No significant differences in postoperative complications were observed between the 2 groups.

Conclusion

A hemorrhoidectomy using an ultrasonic scalpel is an effective and safe procedure. The ultrasonic scalpel reduces the operation time, the postoperative blood loss, and the postoperative pain. Long-term follow-up with larger-scale studies is required to evaluate normal activity after a hemorrhoidectomy performed with an ultrasonic scalpel.

Stapled Haemorrhoidectomy-Experience With Modified Anoscope

Stapled haemorrhoidectomy (SH) is gradually becoming popular. Though it is a "patient friendly" procedure, it has not become the "gold standard". About 15 % complication rate is reported. A perfect purse-string can avoid many of the complications. The author has made a semicircular hole in the anoscope, which has helped in taking the purse-string at proper depth and at proper distance from the dentate line. A total of 72 cases of SH are performed without any complication. Histopathological examination of donoughts in the first 20 cases shows excision up to the submucosa in 16 cases. Our modified anoscope helps in proper visualisation and proper pick up of the rectal wall for perfect purse-string suture and thus complications are avoided.

Circular mucosal anopexy: Experience and technical considerations

INTRODUCTION

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Persistent anal and pelvic floor pain after PPH and STARR: surgical management of the fixed scar staple line

BACKGROUND

Persistent anal pain (PAP) after stapled procedures, be it hemorrhoidopexy (PPH) or stapled transanal rectal resection (STARR) may be hardly resolved by medical therapy. The typical objective finding in these patients is the staple line characterized by fixed scar to underlying layers.

METHODS

A total of 21 consecutive patients were operated for PAP after stapled procedure. The scarred staple line was excised and detached from layers below, the mucosal continuity reconstructed by single stitches. From January 2003 to December 2013 1500 patients underwent stapled procedure. Of these patients treated in our unit, 9 (0.6 %) were operated for chronic anal pain and 12 were referred to our center from other hospitals.

RESULTS

Fifteen (71.4 %) patients resolved and do not take any drugs for pain; an overall of 85.7 % (18/21) improved their clinical status. Mean time between the beginning of symptoms and the operation was 4.27 months (range 1-18 months). We divided the patients into three groups: before 3 months, between 3 and 6 months and after 6 months from the beginning of symptoms to the operation. The best results were in the first group with 100 % pain relief and satisfactory functional results.

CONCLUSIONS

The relief of PAP after stapled procedure, in which we recognize a scarred and fixed staple line, depends by the early recognition of this typical finding. The authors suggest the surgical treatment not later than 3-6 months after the onset of symptoms to achieve the best results.

Tailored prolapse surgery for the treatment of hemorrhoids with a new dedicated device: TST Starr plus

PURPOSE

The aim of the study was to assess the results of the stapled transanal procedure in the treatment of hemorrhoidal prolapse in terms of postoperative complications and recurrence rate using a new dedicated device, TST Starr plus.

METHODS

Patients affected by III-IV degree hemorrhoidal prolapsed that underwent stapled transanal resection with the TST Starr plus were included in the present study. Results of the procedure with perioperative complications, postoperative complications, and recurrence rate were reported.

RESULTS

From November 2012 to October 2014, 52 patients (19 females) were enrolled in the study. The main symptoms were prolapse (100 %) and bleeding (28.8 %). Transanal rectal resection was performed with parachute technique in 24 patients (46.2 %) and purse string technique in 23 patients (53.8 %). A mild hematoma at the suture line occurred in one patient (1.9 %). Postoperative bleeding was reported in three patients (5.7 %), in one of which, reoperation was necessary (1.9 %). Tenesmus occurred in one patient (1.9 %), and it was resolved with medical therapy. Urgency was reported in nine patients (17.1 %) at 7 days after surgery. Of these, three patients (5.7 %) complained urgency at the median follow-up of 14.5 months. Reoperation was performed in one patient (1.9 %) for chronic anal pain for rigid suture fixed on the deep plans. Occasional bleeding was reported in four patients (7.7 %). No recurrence of prolapse was reported at a median of 14.5 months after surgery, even if one patient (1.9 %) had a partial recurrent prolapse of a downstaged single pile.

CONCLUSIONS

TST Starr plus seems to be safe and effective for a tailored transanal stapled surgery for the treatment of III-IV degree hemorrhoidal prolapse. The new conformation and innovative technology of the stapler seems to reduce some postoperative complications and recurrence rate.

Impact of less invasive treatments including sclerotherapy with a new agent and hemorrhoidopexy for prolapsing internal hemorrhoids

Conventional hemorrhoidectomy is applied for the treatment of prolapsing internal hemorrhoids. Recently, less-invasive treatments such as sclerotherapy using aluminum potassium sulphate/tannic acid (ALTA) and a procedure for prolapse and hemorrhoids (PPH) have been introduced. We compared the results of sclerotherapy with ALTA and an improved type of PPH03 with those of hemorrhoidectomy. Between January 2006 and March 2009, we performed hemorrhoidectomy in 464 patients, ALTA in 940 patients, and PPH in 148 patients with second- and third-degree internal hemorrhoids according to the Goligher's classification. The volume of ALTA injected into a hemorrhoid was 7.3 ± 2.2 (mean ± SD) mL. The duration of the operation was significantly shorter in ALTA (13 ± 2 minutes) than in hemorrhoidectomy (43 ± 5 minutes) or PPH (32 ± 12 minutes). Postoperative pain, requiring intravenous pain medications, occurred in 65 cases (14%) in hemorrhoidectomy, in 16 cases (1.7%) in ALTA, and in 1 case (0.7%) in PPH. The disappearance rates of prolapse were 100% in hemorrhoidectomy, 96% in ALTA, and 98.6% in PPH. ALTA can be performed on an outpatient basis without any severe pain or complication, and PPH is a useful alternative treatment with less pain. Less-invasive treatments are beneficial when performed with care to avoid complications.

Short- and long-term results of harmonic scalpel hemorrhoidectomy versus stapler hemorrhoidopexy in treatment of hemorrhoidal disease

PURPOSE

In this prospective randomized study, our aim is to compare the short- and long-term results of harmonic scalpel hemorrhoidectomy (HSH) and stapler hemorrhoidopexy (SH) methods in the surgical treatment of Grade III and Grade IV hemorrhoidal disease.

METHODS

Ninety-nine consecutive patients diagnosed with Grade III or Grade IV internal hemorrhoidal disease were included in the study. Patients were randomized to HSH (n = 48) or SH (n = 51) treatments. Data on patient demographic and clinical characteristics, operative details, postoperative pain score on a visual analog scale, additional analgesic requirement, postoperative short- and long-term complications, and recurrence of hemorrhoidal disease were also recorded. Patients were regularly followed for a total period of 24 (6-36) months.

RESULTS

The patient demographic and clinical characteristics were similar in the two groups. The operative time was significantly shorter in the HSH group compared with the SH group. Overall pain scores were not significantly different between the groups, although severe pain was significantly more common in the HSH group. Recurrence was significantly lower in the HSH group compared with the SH group.

CONCLUSION

HSH and SH are both safe and effective methods for surgical treatment of Grade III and Grade IV hemorrhoidal disease. In our study, the HSH method was determined to be safer, easier, and faster to perform, and associated with fewer long-term recurrences than the SH method.

Is Stapled Hemorrhoidectomy a Safe Procedure for Third and Fourth Grade Hemorrhoids? An Experience at Civil Hospital Karachi

Hemorrhoids are amongst the most frequent anorectal conditions affecting approximately 4-36 % of the general population. The study was carried out to assess the clinical consequences of stapled hemorrhoidectomy comparing results with other published literature regarding postoperative pain, bleeding, incontinence, and other complications. A total of 120 patients were included in this study with symptomatic grade 3 or 4 prolapsed hemorrhoids, who underwent stapled hemorrhoidectomy from January 2006 to January 2012 at the Civil Hospital Karachi, Pakistan. In 92 patients (76.6 %), proctological examination showed grade 3 hemorrhoids. Fourth degree hemorrhoids were found in 28 cases (23.4 %). Hospitalization time ranged between 1 and 3 days (median time was 34 h). Seventy-eight patients were discharged on the first postoperative day, without severe pain, and the remaining 42 patients were discharge on the third day. Two cases of postoperative pain and thrombosis were found as postoperative complications. Stapled hemorrhoidectomy is a safe and quick procedure associated with less pain, better outcome, and early recovery with shorter hospital stay.

Clinical Outcome Following Hemorrhoid Surgery: a Narrative Review

Surgical therapy guaranties satisfactory results, which are significantly better than those obtained with conservative therapies, especially for Grade III and IV hemorrhoids. In this review, we present and discuss the results of the most diffuse surgical techniques for hemorrhoids. Traditional surgery for hemorrhoids aims to remove the hemorrhoids, with closure (Fergusson's technique) or without closure (Milligan-Morgan procedure) of the ensuing defect. This traditional approach is effective, but causes a significant postoperative pain because of wide external wounds in the innervated perianal skin. Stapled hemorrhoidopexy, proposed by Longo, has gained a vast acceptance because of less postoperative pain and faster return to normal activities. In the recent literature, a significant incidence of recurrence after stapled hemorrhoidopexy was reported, when compared with conventional hemorrhoidectomy. Double stapler hemorrhoidopexy may be an alternative to simple stapled hemorrhoidopexy to reduce the recurrence in advanced hemorrhoidal prolapse. Transanal hemorrhoidal deartertialization was showed to be as effective as stapled hemorrhoidopexy in terms of treatment success, complications, and incidence recurrence. However, further high-quality trials are recommended to assess the efficacy and safety of this technique.

Stapled anopexy and STARR in surgical treatment of haemorrhoidal disease

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

Moxibustion Therapy at CV4 Prevents Postoperative Dysuria after Procedure for Prolapse and Hemorrhoids

Objective. To explore the intervention methods of the patients with dysuria after performing the procedure for prolapse and hemorrhoids (PPH). Methods. 100 cases with hemorrhoids were randomly divided into experimental and control groups. The control group received routine nursing care. As comparison, the experimental group, on the basis of conventional care, was treated with moxa roll moxibustion 1 hour after the operation for 30 minutes. The autonomous urination within 1 h, 2 h, 4 h, 6 h, and 8 h after operation and the catheterization rate 8 h after operation of two groups of patients were observed. Results. The median time of autonomous urination of control group (8 h) was significantly greater than that of the experimental group (6 h) (P < 0.001). Cox regression analysis showed that the moxibustion therapy was positively correlated with automatic micturition in the patients after PPH. The probability of automatic micturition in the experimental group was 2.032 times that in the control group (RR = 2.032, 95% CI: 1.278~3.230). The catheterization rate of control group (38%) was significantly higher than that of the experimental group (10%) (P < 0.001). Conclusion. The Guanyuan acupoint moxibustion can prevent dysuria after PPH and reduce the urethral catheterization.

Correlation of histopathology with anorectal manometry following stapled hemorrhoidopexy

Purpose

The removal of smooth muscle during stapled hemorrhoidopexy raises concerns regarding its effects on postoperative anorectal function. The purpose of this study was to evaluate the correlation between the amount of muscle removed and changes in anorectal manometry following stapled hemorrhoidopexy.

Methods

Patients with symptomatic II, III, or IV degree hemorrhoids that underwent stapled hemorrhoidopexy between January 2008 and May 2011 were included in this study. Anorectal manometry was performed preoperatively and at three months postoperatively. The resected doughnuts were examined histologically, and the thicknesses of muscle fibers were evaluated.

Results

Eighty-five patients (34 males) with a median age of 47 years were included. Muscularis propria fibers were identified in 63 of 85 pathologic specimens (74.1%). The median thickness of the muscle fibers was 1.58 ± 1.21 mm (0 to 4.5 mm). The mean resting pressure decreased by approximately 7 mmHg after operation in the 85 patients (P = 0.019). In patients with muscle incorporation, there was a significant difference in mean resting pressure (P = 0.041). In the analysis of the correlation of the difference in anorectal manometry results ([the result of postsurgical anorectal manometry] - [the result of presurgical anorectal manometry]) to the thickness of muscle fibers, no significant differences were seen. No patients presented with fecal incontinence.

Conclusion

Although the incidence of fecal incontinence is very low, muscle incorporation in the resected doughnuts following stapled hemorrhoidopexy may affect anorectal pressure. Therefore, surgeons should endeavor to minimize internal sphincter injury during stapled hemorrhoidopexy.

Stapled hemorrhoidectomy; results of a prospective clinical trial in saudi arabia

OBJECTIVES

This study was designed to evaluate the effectiveness of stapled hemorrhoidectomy (SH) in terms of cure of the symptoms and post-operative pain control.

MATERIAL AND METHODS

In this prospective clinical study, SH (Ethicon Endo-surgery, Cincinnati, OH) was performed for all patients with grade III and grade IV hemorrhoids, presenting to the surgical clinics of Ohud and Meeqat Hospitals Almadinah Almunawwarah Saudi Arabia. The results of SH were evaluated by a questionnaire focusing on the relief of symptoms, severity of post operative pain, and complications of SH.

RESULTS

Thirty patients (21 males and 9 females); with a mean age of 39.6 years were recruited in this study. Twenty six (86%) patients had grade III and 4 (14%) presented with grade IV hemorrhoids. Perianal prolapse was the most frequent presentation reported in 23 (76%). Mean operating time was 21.7 minutes (range; 17-36 minutes) whereas mean hospital stay was 1.9 days. Post-operative pain was tolerable (non-persistent) in 28 (93%) cases whereas 2 (7%) experienced mild pain requiring additional analgesia. Urinary retention was the most common complication found in 5 (16%) patients. All patients were cured of the hemorrhoids Conclusion: SH is a safe, rapid, and convenient surgical remedy for grade III and grade IV hemorrhoids with low rate of complications, minimal postoepative pain, and early discharge from the hospital.

Meta-analysis of stapled hemorrhoidopexy vs LigaSure hemorrhoidectomy

AIM: To compare outcome of stapled hemorrhoidopexy (SH) vs LigaSure hemorrhoidectomy (LH) by a meta-analysis of available randomized controlled trials (RCTs).

METHODS: Databases, including PubMed, EMBASE, the Cochrane Library, and the Science Citation Index updated to December 2012, were searched. The main outcomes measured were operating time, early postoperative pain, postoperative urinary retention and bleeding, wound problems, gas or fecal incontinence, anal stenosis, length of hospital stay, residual skin tags, prolapse, and recurrence. The meta-analysis was performed using the free software Review Manager. Differences observed between the two groups were expressed as the odds ratio (OR) with 95%CI. A fixed-effects model was used to pool data when statistical heterogeneity was not present. If statistical heterogeneity was present (P < 0.05), a random-effects model was used.

RESULTS: The initial search identified 10 publications. After screening, five RCTs published as full articles were included in this meta-analysis. Among the five studies, all described a comparison of the patient baseline characteristics and showed that there was no statistically significant difference between the two groups. Although most of the analyzed outcomes were similar between the two operative techniques, the operating time for SH was significantly longer than for LH (P < 0.00001; OR= -6.39, 95%CI: -7.68 - -5.10). The incidence of residual skin tags and prolapse was significantly lower in the LH group than in the SH group [2/111 (1.8%) vs 16/105 (15.2%); P = 0.0004; OR= 0.17, 95%CI: 0.06-0.45). The incidence of recurrence after the procedures was significantly lower in the LH group than in the SH group [2/173 (1.2%) vs 13/174 (7.5%); P = 0.003; OR= 0.21, 95%CI: 0.07-0.59].

CONCLUSION: Both SH and LH are probably equally valuable techniques in modern hemorrhoid surgery. However, LigaSure might have slightly favorable immediate postoperative results and technical advantages.

Stapled haemorrhoidopexy for haemorrhoids: a review of our early experience

Haemorrhoids is one of the most common problems seen in surgical OPD. Open haemorrhoidectomy has remained the gold standard for a long time with a high post-operative morbidity. The quest for a better understanding of the pathology of haemorrhoids resulted in the evolvement of stapler haemorrhoidopexy. Our aim is to study the efficacy of stapler haemorrhoidopexy with regards to role of immediate post-operative morbidity. A prospective study of 50 patients (n = 50) with the second- and third-degree symptomatic haemorrhoids was done. The mean age of the patients was 44.1 years. Fourteen patients had co-morbid conditions. The average duration of the operation was 29 min. Patients with the second-degree haemorrhoids had higher rate of complication. The complication rate was 32%. Three patients had urinary retention. Two patients had minor bleeding, and one patient experienced transient discharge. The mean analgesic requirement was 2.4 tramadol, 50 mg injections. Ten patients had significant post-operative pain. Average length of hospital stay was 2.7 days. There were no symptomatic recurrences till date.

Stapled anopexy as a day surgery procedure: our experience over 400 cases

BACKGROUND

In 1988, Longo proposed a new treatment for haemorrhoidal disease. In western countries day surgery procedures are becoming more and more common. We propose a new protocol for outpatient haemorrhoidopexy.

PATIENTS AND METHODS

From 2003 to 2010, we performed 403 out-patient stapled haemorrhoidopexies under spinal anaesthesia, on patients with symptomatic grade III and IV haemorrhoid disease. We used PPH 01 and PPH 03 staplers (Ethicon Endosurgery, Cincinnati, OH, USA). We assessed early and late postoperative pain with a Visual Analogue Scale (VAS), and clinical postoperative examinations were performed 7 days, 6 months, and 1, 3 and 5 years after surgery.

RESULTS

The mean surgery time was about 20 min (range 13-39 min). Out of 403 patients, 41 were not dischargeable as a result of urine retention, severe pain or mild bleeding. Twenty-two patients reported transient faecal urgency, while no patient complained of anal incontinence.

CONCLUSIONS

Our experience with 403 patients demonstrated that stapled haemorrhoidopexy is feasible and safe as a day surgery procedure. However, careful preoperative planning is necessary in order to evaluate the patients' health status and the consequent perioperative and postoperative risk. Our results are positive in terms of surgical safety and postoperative recovery time.

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

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

Hemoperitoneum: a rare complication of hemorrhoid treatment

Pile suturing has always been used by surgeons to treat hemorrhoidal disease. We report a case of hemoperitoneum complicating a pile suture. Ultrasonography and computed tomography scan indicated the need for an emergency laparoscopic procedure and conservative management. As other authors have pointed out, we do not know how to prevent this type of complication. This case suggests the possibility of life-threatening complications following treatment procedures for hemorrhoids and underlines the importance of conservative treatment when this is possible.

Hemorrhoids: from basic pathophysiology to clinical management

This review discusses the pathophysiology, epidemiology, risk factors, classification, clinical evaluation, and current non-operative and operative treatment of hemorrhoids. Hemorrhoids are defined as the symptomatic enlargement and distal displacement of the normal anal cushions. The most common symptom of hemorrhoids is rectal bleeding associated with bowel movement. The abnormal dilatation and distortion of the vascular channel, together with destructive changes in the supporting connective tissue within the anal cushion, is a paramount finding of hemorrhoids. It appears that the dysregulation of the vascular tone and vascular hyperplasia might play an important role in hemorrhoidal development, and could be a potential target for medical treatment. In most instances, hemorrhoids are treated conservatively, using many methods such as lifestyle modification, fiber supplement, suppository-delivered anti-inflammatory drugs, and administration of venotonic drugs. Non-operative approaches include sclerotherapy and, preferably, rubber band ligation. An operation is indicated when non-operative approaches have failed or complications have occurred. Several surgical approaches for treating hemorrhoids have been introduced including hemorrhoidectomy and stapled hemorrhoidopexy, but postoperative pain is invariable. Some of the surgical treatments potentially cause appreciable morbidity such as anal stricture and incontinence. The applications and outcomes of each treatment are thoroughly discussed.

Rectal perforation with life-threatening peritonitis following stapled haemorrhoidopexy

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

A one-year follow-up of the quality of life after stapled hemorrhoidopexy

Articles presenting treatment outcomes of stapled hemorrhoidopexy are rarely based on detailed analyses of the quality of life.The aim of the study was the assessment of changes within one year of treatment in the quality of life of patients who underwent stapled hemorrhoidopexy using QLQ-C30 form (version 3).

MATERIAL AND METHODS

120 patients with grade III and IV internal hemorrhoidal disease treated with stapled hemorrhoidopexy were enrolled in the study. They answered questions from QLQ-C30 form and were subjected to examination a day before surgery and 1 day, 7 days, 4 weeks, 6 and 12 months after surgery. Assessment included operation site inspection, pain intensity measurement in VAS scale and parameters incorporated in QLQ-C30 form evaluation.

RESULTS

The overall quality of life decreased immediately after surgery (a day after 50% vs. 60% before surgery), but rapidly improved in one week and in one month periods (60% and 80% consecutively) reaching a plateau one month after surgery. Early complications occurred in 6 patients (5%). Recurrence of the disease was not observed. Bleeding from anastomosis site and severe pain in anal area immediately post surgery as a result of improper purse-string suture placement were the main complications.

CONCLUSIONS

In patients with grade III or IV hemorrhoidal disease, stapled hemorrhoidopexy ensures a rapid improvement in the quality of life after surgery to the level experienced prior to the operation. 7-day convalescence period is sufficient. After one month, the overall quality of life improves significantly and reaches a plateau.

Care with regard to details improves the outcome of Longo mucoprolapsectomy: long term follow up

In this study we evaluated the results of stapled hemorrhoidopexy considering the histological features of the resected tissue obtained after the intervention, the staple line height and the improvement of the quality of life after the treatment. From January 2003 to December 2006, 72 patients with symptomatic grade 3 and 4 hemorrhoid that underwent stapled hemorrhoidopexy in our clinic were enroled in the study. Preoperative, intraoperative and postoperative characteristics of the patients were evaluated, including demographics, staple line height, specimen histology, complications, recurrence, day to return to work, quality of life (QoL) score and use of analgesics. Staple line height was always above 2.5 cm from the dentate line. Smooth muscle fibers were observed in 97.2%. The complication rate was 18%. Bleeding was observed in 5.5%. Fecal urgency was referred in 6.9%. Recurrence rate was 6.9%. Mean follow-up was 68 months. Hemorrhoidopexy is safe and effective but extreme attention must be paid to some critical details. We consider the placement of the purse string suture as a critical factor in the outcome of the patients. We find that some amount of the muscle fibers would invariably be involved in the resected specimen, without any significant impact in the clinical outcome or in the quality of life improvement.

Agraffectomy after low rectal stapling procedures for hemorrhoids and rectocele

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Stapled Hemorrhoidopexy as a Day-Surgery Procedure

In the last 10 years, stapled hemorrhoidectomy has gained worldwide consensus. We studied a day-surgery stapled hemorrhoidopexy protocol to allow shorter recovery time and cost reduction. From 2003 to 2008, we performed 292 outpatient stapled hemorrhoidopexies under spinal or local anesthesia including symptomatic Grade III and IV hemorrhoid disease. We used PPH 01 to PPH 03 staplers. We assessed early and late postoperative pain with a Visual Analog Scale, whereas clinical postoperative examinations were performed at sev7en days, 6 months, and 1, 3, and 5 years after surgery. The mean surgery time was approximately 18 minutes (range, 13 to 39 minutes). Of 292 patients, 39 were not dischargeable for urine retention, severe pain, or mild bleeding. Four other patients were rehospitalized within 8 days for bleeding. Twenty-one patients reported transient fecal urgency, whereas nobody reported anal incontinence. We can conclude that stapled hemorrhoidopexy is a safe and effective procedure if performed in a day-surgery unit. The complication rate is comparable to that of inpatient procedures.

The fate and significance of retained staples after stapled haemorrhoidopexy

AIM

We studied the fate of staples after stapled haemorrhoidectomy (SH) and reviewed the complications they may cause.

METHOD

A survey was carried among 16 surgeons experienced at performing SH to assess their knowledge regarding retained staples. In addition, plain pelvic radiology was used to visualize residual staples at different time intervals after SH in 45 patients.

RESULTS

Ten (63%) surgeons informed their patients that the staples would be shed within 3 months of SH. Regardless of the timing of surgery, part of the staple line was radiologically visible in all patients, and in 19 patients (45%) the staple line was completely visible.

CONCLUSION

Contrary to the common belief, the majority of staples are retained after SH.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

Observational study.

SETTING AND PATIENTS

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

INTERVENTION

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

MAIN OUTCOME MEASURES

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

RESULTS

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

LIMITATIONS

Lack of a comparative group.

CONCLUSION

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

Transanal haemorrhoidal dearterialization (THD) for selected fourth-degree haemorrhoids

BACKGROUND

Traditional treatment of fourth-degree haemorrhoidal disease (HD) is conventional haemorrhoidectomy and is frequently associated with significant pain and morbidity. In recent years, the use of transanal haemorrhoidal dearterialization (THD) for the treatment of HD has increased. The procedure aims to decrease the arterial blood flow to the haemorrhoids. Moreover, since a rectal mucopexy to treat the prolapsing component has become part of the THD technique, this treatment is also indicated for more advanced HD. The aim of this study was to assess the possible role of THD in the treatment of fourth-degree HD.

METHODS

All patients with non-fibrotic fourth-degree HD were offered the THD procedure with mucopexy. Excision of skin tags was added to THD and mucopexy, when needed. A specific score was used to assess HD severity, ranging from 0 (no HD) to 20 (worst HD). The mean preoperative score was 18.1 ± 1.8.

RESULTS

Thirty-five consecutive patients (mean age 50.4 ± 13.8 years; 19 men) with fourth-degree HD were prospectively enroled. An average of 6 arteries were identified and transfixed. Mucopexy was achieved with a 3-6 sector plication of rectal mucosa. Mean operating time was 33 ± 12 min. No intraoperative complications were recorded. Postoperative morbidity included 3 (8.6%) haemorrhoidal thromboses (1 requiring surgery) and 2 (5.7%) episodes of bleeding (1 requiring surgical haemostasis). Five patients (14.3%) had urinary retention requiring catheterization. At a median follow-up of 10 months (range 2-28 months), symptoms had resolved or significantly improved in 33 (94%) patients. Nine patients (25.7%) reported irregular bleeding, 3 patients (8.6%) mild anal pain, 4 patients (11.4%) transient anal burning and 4 patients (11.4%) tenesmus. Ten patients (28.6%) experienced some degree of residual prolapse, significant only in 2 (5.7%) who required further surgery. There was no anorectal stenosis, and no faecal incontinence was reported. At a median follow-up of 10 months, the symptomatic score was 2.5 ± 2.5 (P < 0.005).

CONCLUSION

Transanal haemorrhoidal dearterialization seems to be a safe and effective treatment for fourth-degree HD providing a significant improvement of symptoms for the majority of patients. When present, persisting symptoms are mostly transient, occasional or limited in severity, and only a very few patients require further intervention. Larger series and longer follow-up to further assess the role of THD in this challenging group of pts.