Ferguson hemorrhoidectomy: long-term results and patient satisfaction after Ferguson's hemorrhoidectomy

The Use of Transanal Hemorrhoidal Dearterialization for Treatment of Hemorrhoid Disease at a Single Institution

Transanal hemorrhoidal dearterialization (THD) is a relatively new, minimally invasive approach for the treatment of hemorrhoid disease. Despite increasing use of this procedure, there remains scarce United States-based data on the perioperative variables affected by this surgical technique. This article details the experience with THD at a single institution. This is a single-institution study that includes consecutive patients that underwent THD at George Washington University from November 2011 to April 2014. After Institutional Review Board approval, retrospective chart review was performed. Patient demographic information, preoperative management of hemorrhoid disease, and quality of life indicators after THD were collected for all patients. A total of 96 patients underwent THD during the period of investigation. A majority of the patients were male and all patients had grade II or III hemorrhoids. Most patients who underwent THD presented with rectal bleeding. Four patients required postoperative admission to the hospital for pain control, eight patients experienced constipation postoperatively, and one patient had recurrence of their hemorrhoid disease at 30-day follow-up. No patients required admission to the hospital for postoperative hemorrhage and none experienced urinary retention or incontinence of flatus or stool. THD is a feasible alternative to Ferguson hemorrhoidectomy for the surgical treatment of grade II and III hemorrhoidal disease. Future prospective studies are needed to help improve patient selection for each respective surgical approach.

An Assessment of Margins after Lumpectomy in Breast Cancer Management

We performed this study to evaluate our indications for margin re-excision (MRE) in the management of cancer patients opting for breast conservation therapy (BCT). We identified patients choosing breast conservation therapy from January 2012 to May 2014. Margins were considered negative if >2 mm, close if <2 mm, and positive if ink was detected abutting tumor. Patients with close and positive margins underwent MRE. We identified 247 patients of which 190 had negative margins and did not require MRE, 46 patients had a close margin, and 11 had a positive margin, leading to an MRE rate of 23 per cent (57 of 247). The following variables were evaluated: tumor size, stage, estrogen receptor, progesterone receptor, HER2/neu receptor, and node status. None predicted the presence of tumor in the MRE specimen ( P > 0.05). Patients with close margins had a 6.5 per cent (3 of 46), and patients with positive margins had a 36.4 per cent (4 of 11) incidence of tumor in the MRE specimens; this difference was statistically significant ( P = 0.02). The low rate of finding tumor in MRE specimens of patients with close margins after lumpectomy for breast carcinoma argues for limiting MRE to patients with positive margins (ink on tumor) only. We have adopted this approach in our institution.

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.

Dexmedetomidine as an adjunct to epidural analgesia after abdominal surgery in elderly intensive care patients: A prospective, double-blind, clinical trial

BACKGROUND

The ideal postoperative analgesia management of elderly surgical patients in intensive care units (ICUs) is continually being investigated.

OBJECTIVE

The purpose of this study was to assess the effectiveness and tolerability of IV administration of dexmedetomidine as an adjunct to a low-dose epidural bupivacaine infusion for postoperative analgesia after abdominal surgery in elderly patients in the ICU.

METHODS

ICU patients aged >70 years undergoing abdominal surgery were eligible for the study. A lumbar epidural catheter was inserted at the beginning of the surgery with no medication. On arrival at the ICU, the catheter was loaded with 0.25% bupivacaine 25 mg at the T8 to T10 sensory level, and a continuous infusion of 0.125% bupivacaine was started at 4 to 6 mL/h in combination with patient-controlled epidural analgesia (PCEA) of fentanyl (4 μg/bolus) for pain treatment. Patients in the treatment group received dexmedetomidine as an IV loading dose of 0.6 pg/kg for 30 minutes followed by continuous infusion at 0.2 μg/kg · h(-1). Patients in the control group were not administered dexmedetomidine. The effectiveness of the pain relief was determined using a visual analog scale (VAS) (0 = no pain to 10 = worst pain imaginable) at rest. VAS score, heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure, and arterial blood gases were monitored periodically for 24 hours after surgery. If required, tenoxicam (20-mg IV bolus) was used to ensure a VAS score of ≤3. The number of times PCEA and tenoxicam were administered and the occurrence of adverse events (AEs) were also recorded.

RESULTS

Sixty patients (34 men, 26 women; mean [SD] age, 75.96 [4.25] years; mean [SD] weight, 74.13 [10.62] kg) were included in the study. VAS scores were significantly lower in the dexmedetomidine group compared with the control group at hours 1, 2, and 12 (VAS [hour 1]: 2.8 [0.4], P < 0.001; VAS [hour 2]: 2.7 [0.5], P < 0.001; and VAS [hour 12]: 0.9 [0.7], P 0.044). The mean number of administrations of fentanyl via PCEA was significantly greater in the control group compared with the dexmedetomidine group (2.20 vs 6.63 times; P < 0.001). The mean number of administrations of tenoxicam was significantly lower in the treatment group than the control group (0.27 vs 1.07 times; P < 0.001). In the control group, the decreases in sedation at 0, 8, 12, 16, and 20 hours were significant compared with baseline (P = 0.024, P = 0.001, P = 0.020, P < 0.001, and P = 0.005, respectively). Mean HR, SBR and AEs (eg, bradycardia [HR <60 beats/min], respiratory depression [respiratory rate <8 breaths/min], hypotension \SBP <90 mm Hg], oversedation, hypoxia, and hypercapnia) decreased significantly in the dexmedetomidine group (all, P < 0.05). Significantly more patients in the dexmedetomidine group rated their satisfaction with postoperative pain control as excellent compared with the control group (12 vs 6 patients; P = 0.014).

CONCLUSION

Intravenous dexmedetomidine was effective and generally well tolerated as an analgesic adjunct to epidural low-dose bupivacaine infusion for pain treatment, with lower need for opioids after abdominal surgery in these elderly intensive care patients than in the control group.

Hemorrhoids and fistulas: new solutions to old problems

Symptoms thought related to hemorrhoids must be carefully considered before intervention. The first line of therapy for any hemorrhoidal complaint remains conservative management with increased fluid and fiber intake and appropriate modification of toileting behavior. Bleeding in grades 1 and 2 hemorrhoids that does not respond to this can be satisfactorily and safely managed with office-based therapies; some grade 3 hemorrhoids would also respond to this, though more treatment sessions would likely be required. Operative therapy is the best choice for management of persistently symptomatic grade 2 disease and for grades 3 and 4 symptomatic hemorrhoids as well. With proper patient selection and preparation, along with a familiarity with instrumentation and techniques, good results can be obtained with newer operative interventions for internal hemorrhoids. Outcomes must always be compared with those obtained with classic excisional hemorrhoidectomy.

An evaluation of Milligan-Morgan and Ferguson procedures for haemorrhoidectomy at Liaquat University Hospital Jamshoro, Hyderabad, Pakistan

OBJECTIVE

o compare the outcome of Milligan-Morgan (MMH) and Ferguson (FH) techniques for haemorrhoidectomy with regard to postoperative pain, control of bleeding, early mobilization of patients and wound healing.

METHODOLOGY

In this prospective, randomized clinical study conducted between January 2005 to December 2008, 213 patients with late 2(nd) degree; third or fourth degree hemorrhoids were assigned to two groups. One hundred ten patients in group A were operated by an open method and 103 patients in group B were operated by closed method.

RESULTS

Age ranged from 22-70 years with mean age of 45.5 years. Peak incidence was between 41-50 years. Out of 213 patients, 170 (79.81%) were male and 43 (20.18%) were females. The mean ± SD operating time was significantly more in group B (31.3±4.8 min) than group A (25.2±5.6). The duration of hospitalization and duration off from work was more in group A than the group B. Wound healing was quicker in group B than the group A. Post operative pain scores were significantly low in the Group A than Group B during first 24 hours and at first bowel movements. Reactionary hemorrhage occurred in 4 (3.63%) patients of group A, no patient in group B developed this complication. Retention of urine was seen in 13 (11.81%) patients in group A and 4 (3.88%) in group B. No patient in group A developed anal stenosis, while 3 (2.91%) patients in group B developed anal stenosis. Wound infection was one (0.9%) in group A and two (1.9%) in group B. Two (3.63%) patients in group A came with recurrent hemorrhoids and in group B, only one (0.97%) patient reported recurrence.

CONCLUSIONS

The closed technique is more beneficial with respect to postoperative pain, control of bleeding, early mobilization of patients and wound healing.

Results of 666 consecutive patients treated with LigaSure hemorrhoidectomy for symptomatic prolapsed hemorrhoids with a minimum follow-up of 2 years

BACKGROUND

Our aim is to report the outcomes of hemorrhoidectomy performed via LigaSure™ with a minimum follow-up of 2 years.

METHODS

A total of 666 patients underwent hemorrhoidectomy for symptomatic prolapsed hemorrhoids (grade III and IV) via LigaSure between June 2006 and June 2008. Patient demographic and operative data were collected and analyzed.

RESULTS

The mean patient age was 45.4 ± 11.1 years (x ± SD; range, 22-77), and approximately 72% had grade III hemorrhoids. All procedures were performed without complications. The operative time was 18.7 ± 4.1 minutes (range, 9-43), and hospital stay was 1.5 ± 0.6 days (range, 1-4). There was no immediate postoperative bleeding or other procedure-related complications. Twelve (1.8%) patients required urinary catheterization for a maximum of 1 day, and 21 (3.2%) patients had delayed postoperative bleeding. Most cases of bleeding resolved spontaneously; 3 patients (0.4%) required reoperation. A total of 645 patients (96.6%) responded to a follow-up telephone interview at a mean of 36 months (range, 24-49) after hemorrhoidectomy. After 1 year postoperatively, 2 patients received additional excisions for residual skin tags, 1 was treated for an anal stricture, 1 was treated for an anal fistula, and 3 were treated for anal fissures. Minor incontinence (flatus) was present in 11 (1.7%) patients, and 13 (2.0%) experienced mild bleeding caused by residual hemorrhoids; 1 patient underwent rubber-band ligation, and the others were successfully treated medically. No recurrent prolapse or persistent anal pain occurred during the follow-up period. The overall recurrence rate at 2-years follow-up was 3.1%.

CONCLUSION

The long-term recurrence rate after hemorrhoidectomy with LigaSure is low and comparable with conventional hemorrhoidectomy.

Ferguson hemorrhoidectomy: is still the gold standard treatment?

Hemorrhoidectomy remains the most definitive procedure to treat symptomatic grades III and IV hemorrhoids. However, over the years, several modifications have been made to the original operation to improve the outcomes. A total of 693 consecutive patients with grade III and IV hemorrhoids underwent Ferguson hemorrhoidectomy. Our results serve as a standard for comparison conventional hemorrhoidectomy (Ferguson's technique) with recent methods such as stapled hemorrhoidopexy and LigaSure hemorrhoidectomy. We have obtained a very low rate of post-operative pain after Ferguson hemorrhoidectomy (VAS pain score was 2.47 ± 1.1 after a day, 1.34 ± 0.7 after 7 days and 0.51 ± 0.1 after 2 weeks) as to for stapler and LigaSure procedure in the literature. Moreover, long-term results demonstrate high levels of patient satisfaction (the satisfaction was good in 624 patients after 2 weeks and in 658 patients after 1 year) with a low recurrence rates (7 patients had recurrence after 1 year and 21 patients after 2 years). We believe that Ferguson-closed hemorrhoidectomy could still be, at the moment, the gold standard to which other techniques are compared.

Underlying functional bowel disorder may explain patient dissatisfaction after haemorrhoidal surgery

AIM

The aim of this study was to assess patient dissatisfaction and functional symptoms following haemorrhoid surgery, aspects of which are seldom covered in other published series.

METHOD

A self-administered questionnaire was mailed to 359 consecutive patients (prospective database; 198 men, 161 women; median follow up, 59 [1-120] months) who underwent either Milligan-Morgan haemorrhoidectomy (n=205) or stapled haemorrhoidopexy (n=154).

RESULTS

The response rate was 72%; 2.4% of patients had no opinion, 13.6% were dissatisfied, 33.0% were satisfied, and 51.0% were very satisfied with the treatment. Dissatisfied patients were more likely to be women and more likely to have a long history of constipation and irritable bowel syndrome. The duration of surgery and the rates of pre- and postoperative complications did not differ between groups. Residual bleeding (49% vs 32%), prolapse (67% vs 31%) and pain (91% vs 55%) occurred more frequently in the dissatisfied group compared with the satisfied group (P<0.001). Incontinence (4 [0-16] vs 1 [0-15]; P=0.0003) and constipation (19 [1-34] vs 8 [0-31]; P<0.0001) scores were significantly higher in the dissatisfied group compared with satisfied patients. Anal pain was the predominant symptom associated with dissatisfaction in a logistic regression model.

CONCLUSION

Persistent pain remains the major long-term factor associated with dissatisfaction after surgery for haemorrhoids.

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.

Results of 7302 stapled haemorrhoidectomy operations in a single centre: a seven-year review and follow-up questionnaire survey

BACKGROUND

This study aims to evaluate the results of all 7302 stapled haemorrhoidectomy operations performed in a single centre.

METHOD

A retrospective review of all 7302 patients who underwent stapled haemorrhoidectomy at our department over seven years was conducted. The hospital database was reviewed for subsequent readmissions and re-operations. A questionnaire survey was also sent out to all the patients.

RESULTS

A total of 302 patients (4.1%) were admitted with post-operative bleeding and 281 stopped with conservative measures. Twenty one required surgical haemostasis. A total of 301 patients (4.1%) were admitted for an inability to void and 191 (2.6%) had true acute retention of urine, requiring catheterization. There were 124 patients (1.7%) admitted for pain, but all resolved with oral analgesia subsequently. Anal stricture requiring surgery occurred in only 86 patients (1.2%). Serious complications such as staple line dehiscence or anorectal sepsis occurred in seven patients. There were a total of 14 recurrences requiring readmission over this seven-year period, of which 12 were treated successfully with a second haemorrhoidectomy. A total of 1834 patients returned their questionnaire surveys and 95% of the patients reported complete resolution or improvement of their symptoms. Only 27 patients reported subsequent severe bleeding requiring medical attention.

CONCLUSION

Stapled haemorrhoidectomy is safe, and most patients are satisfied with the long-term outcome.

Hemorrhoids

Hemorrhoids are normal vascular structures underlying the distal rectal mucosa and anoderm. Symptomatic hemorrhoidal tissues located above the dentate line are referred to as internal hemorrhoids and produce bleeding and prolapse. Thrombosis in external hemorrhoids results in painful swelling. Symptomatic internal hemorrhoids that fail bowel management programs may be amenable to in-office treatment with rubber band ligation or infrared coagulation. Internal hemorrhoids that fail to respond to these measures or complex internal and external hemorrhoidal disease may require a surgical hemorrhoidectomy, either open or closed. A stapled hemorrhoidopexy treats symptomatic internal hemorrhoids and should be employed with care and only after thorough training of the surgeon because of the risk of rare, severe complications. The choice of procedure should be based on the patient's symptoms, the extent of the hemorrhoidal disease, and the experience of the surgeon.

Randomized controlled trial comparing rubber band ligation with stapled haemorrhoidopexy for Grade II circumferential haemorrhoids: long-term results

OBJECTIVE

An improved understanding of the pathophysiology of haemorrhoids has resulted in the introduction of new surgical techniques including stapled haemorrhoidopexy (SH). This randomized controlled trial compared the long-term effectiveness of SH with rubber band ligation (RBL) in the treatment of grade II circumferential symptomatic haemorrhoids.

METHOD

A consecutive cohort of patients was randomly allocated to either SH or RBL. Data on haemorrhoidal symptoms, Cleveland continence scores, sphincter assessment, SF-36, EQ-5D, HAD score and prior treatment history were assessed at enrollment and reassessed by long-term postal questionnaire. The details were analysed using spss 12.0 from Microsoft Access.

RESULTS

Sixty patients were allocated by computer block randomization. Both groups were balanced for age, sex and symptoms. Recurrence favoured SH [3 vs 11; OR 0.18, 95% CI (0.03 to 0.86), P = 0.028] at 1 year and, at a mean of 40.67 (31-47) months [4 vs 12; OR 0.23, 95% CI (0.05, 0.95); P = 0.039]. SH patients experienced prolonged pain [Median (IQR) = 7 (5,7) vs 3 (1,7), P = 0.008] and took a longer time to return to work [6 (3,7) vs 3 (1,6) days, P = 0.018]. This was no significant difference in quality of life.

CONCLUSION

Stapled haemorrhoidopexy achieved better disease control at 1 year without any major complication. This was sustained in the long-term. Further studies with greater patient numbers are needed to confirm this study.

The outcome of postoperative hemorrhaging following a hemorrhoidectomy

PURPOSE

Postoperative hemorrhage (PH) is rare, but it is widely recognized as a postoperative complication of a hemorrhoidectomy. The assessment of this complication may provide information which can be used to improve the clinical outcome of a patient who has undergone a hemorrhoidectomy.

METHODS

Between January 2006 and December 2007, a total of 1294 patients with symptomatic hemorrhoids underwent a hemorrhoidectomy at our hospital. The patient records were retrospectively analyzed.

RESULTS

In this study, 23 patients had suffered from PH and had undergone a second operation (1.7%). The bleeding points were located as follows: 14 anterior,7 right laterally, 8 left laterally, and 2 posteriorly. Of these patients with early hemorrhage, 1 case was at the anterior, 1 was left lateral, and 2 were posterior. A significant correlation was observed between the period and the location of postoperative hemorrhage (P = 0.0023). From one to four piles were excised (1 in 264 patients, 2 in 240 patients, 3 in 702 patients, 4 in 88 patients). A significant correlation was also observed between the number of piles and the occurrence of PH (P = 0.032).

CONCLUSIONS

At the posterior wall, a late period hemorrhage is less likely to be found than an early period hemorrhage. It was found that the more piles that were excised, the greater the occurrence of PH.

The evaluation of CEEA 34 for stapled hemorrhoidectomy: results of a prospective clinical trial and patient satisfaction

INTRODUCTION

Stapled hemorrhoidectomy (SH) has routinely been performed using Procedure for Prolapse and Hemorrhoids Proximate Hemorrhoidal Circular Staplers (Ethicon Endo-surgery, Cincinnati, OH). Premium Plus CEEA 34 (Tyco Healthcare, New Haven, CT) has been recently introduced for SH. This study aims to review the effectiveness of CEEA 34 for SH.

METHODS

From April to June 2007, the SH procedure was performed or supervised by 5 experienced consultant surgeons. A quality of life telephone survey was performed within 4 to 6 weeks postoperatively.

RESULTS

Two hundred thirteen patients (52% men and 48% women) with a median age of 46 years (range 26-78 years) underwent SH during the trial period. Median duration of surgery was 10 minutes (range 5-35 minutes). Ninety-seven percent underwent SH for third- and fourth-degree piles. Ten patients (4.7%) had bleeding postoperatively in the first week that ceased with adrenaline injection or pack, and 2 required transfusions. Eighty-three percent participated in the quality of life survey, and 92% of these patients expressed satisfaction with the outcome of the procedure.

CONCLUSION

CEEA 34 for SH is safe and effective with few postoperative complications and high patient satisfaction.

Long-term outcome of stapled hemorrhoidopexy for Grade III and Grade IV hemorrhoids

PURPOSE

This study was designed to assess the long-term results of stapled hemorrhoidopexy in 291 patients with Grade III and Grade IV hemorrhoids after a minimum follow-up of five years.

METHODS

Records of patients submitted to stapled hemorrhoidopexy for Grade III and Grade IV hemorrhoids between January 1999 and December 2002 were retrospectively analyzed. Long-term outcome was evaluated with a standardized questionnaire and an office visit, including anorectal examination and rigid proctoscopy.

RESULTS

A total of 291 patients with Grade III (57.4 percent) and Grade IV (42.6 percent) hemorrhoids were evaluated. Intraoperative (20.3 percent) and postoperative (4.8 percent) bleeding was the most frequent complication. The questionnaire was submitted to all patients at a median follow-up of 73 (range 60-93) months. There were no symptoms related to hemorrhoids in 65.3 percent of patients, moderate symptoms in 25.4 percent of patients, and severe symptoms in 9.3 percent of patients. Fifty-three (18.2 percent) patients had recurrence. Reoperation was necessary in 21 (7.2 percent) patients (4 in Grade III hemorrhoids and 17 in Grade IV hemorrhoids; P < 0.001), with no recurrent symptoms and/or prolapse. Patient satisfaction for operation was 89.7 percent.

CONCLUSIONS

Stapled hemorrhoidopexy is a safe and effective treatment for Grade III and Grade IV hemorrhoids. Recurrence requiring reoperation was higher in Grade IV hemorrhoids than in Grade III hemorrhoids.

Effect of body mass index on the risk of anal incontinence and defecatory dysfunction in women

OBJECTIVE

The primary objective was to estimate the effect of body mass index on the risk of anal incontinence and defecatory dysfunction in a tertiary referral urogynecologic population.

STUDY DESIGN

This was a cross-sectional study, including 519 new patients. Exposure was defined as body mass index. The primary outcome was any reported anal incontinence. The secondary outcome was any defecatory dysfunction. We used multiple logistic regression to estimate odds ratios and 95% confidence intervals for the effect of body mass index on anal incontinence and defecatory dysfunction.

RESULTS

After adjusting for confounders, every 5 unit increase in body mass index was associated with a significantly increased odds of anal incontinence (odds ratio 1.25; 95% confidence interval, 1.09 to 1.44) and a trend toward an increased odds of defecatory dysfunction (odds ratio 1.13; 95% confidence interval, 0.98 to 1.31), although this was not statistically significant.

CONCLUSION

Increasing body mass index is significantly associated with anal incontinence, but not defecatory dysfunction in women.

Stapled hemorrhoidopexy and Milligan Morgan hemorrhoidectomy in the cure of fourth-degree hemorrhoids: long-term evaluation and clinical results

PURPOSE

The long-term results after stapled hemorrhoidopexy compared with Milligan-Morgan procedure are discussed.

METHODS

The clinical data of 100 patients treated by Milligan-Morgan procedure or stapled hemorrhoidopexy for fourth-degree hemorrhoids have been reviewed. All patients were visited and submitted to a questionnaire to evaluate resumption of symptoms, functional results, and recurrence rate.

RESULTS

The mean follow-up was 54 months for stapled hemorrhoidopexy and 92 months for the Milligan-Morgan procedure. Postoperative pain and return to normal activity were worse in the Milligan-Morgan procedure (Visual Analog Scale 8.56 vs. 5.46, P < 0.001; and 2.4 vs. 2 weeks, P value = 0.018). Eight percent of patients who had stapled hemorrhoidopexy complained of spontaneous pain or pain during defecation vs. 0 percent of patients who underwent the Milligan-Morgan procedure. We noted that there was bleeding in 14 percent of stapled hemorrhoidopexy vs. 0 percent of Milligan-Morgan procedure (P < 0.006), tenesmus in 32 percent of stapled hemorrhoidopexy vs. 0 percent of Milligan-Morgan procedure (P < 0.001), and pruritus in 4 percent of stapled hemorrhoidopexy vs. 0 percent of Milligan-Morgan procedure. Minor leakage was similar in the two groups. Flatus impaired control was less frequent in Milligan-Morgan. The relative risk of recurrence for stapled hemorrhoidopexy compared with Milligan-Morgan procedure was 1.18 (95 percent confidence interval 1< relative risk < 1.4). No statistical difference was noted in patients' satisfaction after the procedures.

CONCLUSIONS

Long follow-up seems to indicate more favorable results in Milligan-Morgan procedure in terms of resumption of symptoms and risk of recurrence.

Long-term outcome of a multicentre randomized clinical trial of stapled haemorrhoidopexy versus Milligan-Morgan haemorrhoidectomy

INTRODUCTION

Stapled haemorrhoidopexy is less painful than Milligan-Morgan haemorrhoidectomy, allowing an earlier return to working activities, but its long-term efficacy is not fully established. This study reports the long-term follow-up of a randomized clinical trial comparing the two techniques in 100 patients affected by third- and fourth-degree haemorrhoids.

METHODS

All patients were contacted and invited to attend the clinic to assess long-term functional outcome. The degree of continence and satisfaction were assessed by questionnaire. Anal manometry and anoscopy were performed.

RESULTS

Eighty patients were available after a median follow-up of 87 months. No statistically significant differences were found between the two groups in terms of incontinence, stenosis, pain, bleeding, residual skin tags or recurrent prolapse. A tendency towards a higher recurrence rate was reported in patients with fourth-degree haemorrhoids, irrespective of the technique used. No significant changes in anal manometric values were found after surgery in either group.

CONCLUSION

Both techniques are effective in the long term.

Stapled hemorrhoidopexy is associated with a higher long-term recurrence rate of internal hemorrhoids compared with conventional excisional hemorrhoid surgery

PURPOSE

The purpose of this systematic review was to compare the long-term results of stapled hemorrhoidopexy with conventional excisional hemorrhoidectomy in patients with internal hemorrhoids.

METHODS

A systematic review of all randomized, controlled trials comparing stapled hemorrhoidopexy and conventional hemorrhoidectomy with long-term results was performed by using the Cochrane methodology. The minimum follow-up was six months. Primary outcomes were hemorrhoid recurrence, hemorrhoid symptom recurrence, complications, and pain.

RESULTS

Twelve trials were included. Follow-up varied from six months to four years. Conventional hemorrhoidectomy was more effective in preventing long-term recurrence of hemorrhoids (odds ratio (OR), 3.85; 95 percent confidence interval (CI), 1.47-10.07; P < 0.006). Conventional hemorrhoidectomy also prevents hemorrhoids in studies with follow-up of one year or more (OR, 3.6; 95 percent CI, 1.24-10.49; P < 0.02). Conventional hemorrhoidectomy is superior in preventing the symptom of prolapse (OR, 2.96; 95 percent CI, 1.33-6.58; P < 0.008). Conventional hemorrhoidectomy also is more effective at preventing prolapse in studies with follow-up of one year or more (OR, 2.68; 95 percent CI, 0.98-7.34; P < 0.05). Nonsignificant trends in favor of conventional hemorrhoidectomy were seen in the proportion of asymptomatic patients, bleeding, soiling/difficultly with hygiene/incontinence, the presence of perianal skin tags, and the need for further surgery. Nonsignificant trends in favor of stapled hemorrhoidopexy were seen in pain, pruritus ani, and symptoms of anal obstruction/stenosis.

CONCLUSIONS

Conventional hemorrhoidectomy is superior to stapled hemorrhoidopexy for prevention of postoperative recurrence of internal hemorrhoids. Fewer patients who received conventional hemorrhoidectomy complained of hemorrhoidal prolapse in long-term follow-up compared with stapled hemorrhoidopexy.

Long-term results after stapled hemorrhoidopexy: high patient satisfaction despite frequent postoperative symptoms

PURPOSE

Stapled hemorrhoidopexy has been demonstrated to be advantageous in the short term compared with the traditional techniques. We aimed to evaluate long-term results after stapled hemorrhoidopexy and to assess patient satisfaction in association with postoperative hemorrhoidal symptoms.

METHODS

This prospective study included 216 patients with Grade 2 or 3 hemorrhoids, who had stapled hemorrhoidopexy using the circular stapled technique. The results were evaluated by a standardized questionnaire at least 12 months after the operation. The primary end point was patient satisfaction; secondary end points included specific hemorrhoidal symptoms.

RESULTS

Followup data were obtained for 193 of 216 patients (89 percent) with a median follow-up of 28 (range, 12-53) months, most of whom (89 percent) were satisfied or very satisfied with the surgery. The main preoperative symptom was no longer present postoperatively in 66 percent of patients, was relieved in 28 percent, and had worsened in 2 percent. Postoperative complaints included symptoms of hemorrhoidal prolapse (24 percent of patients), anal bleeding (20 percent), anal pain (25 percent) fecal soiling/leakage (31 percent), fecal urgency (40 percent), and local discomfort (38 percent). Bivariate analysis showed significant associations between each of these symptoms and patient satisfaction. Nine patients (5 percent) were reoperated on during the follow-up period.

CONCLUSIONS

Long-term patient satisfaction was high in most of patients after stapled hemorrhoidopexy for second-degree and third-degree hemorrhoids. However, an unsatisfactory outcome was significantly related to postoperative hemorrhoidal symptoms such as prolapse, fecal soiling/leakage, and new onset of fecal urgency.

Stapled vs open hemorrhoidectomy: long-term outcome of a randomized controlled trial

BACKGROUND AND AIMS

Stapled hemorrhoidectomy is a relatively new procedure, and studies on long-term outcomes are few. We present the results of a 5-year follow-up on patients recruited to a randomized controlled trial comparing stapled and Milligan-Morgan hemorrhoidectomy.

PATIENTS AND METHODS

We performed telephone interviews and office visits between May and July 2005 on patients who had taken part in a randomized controlled trial from May 1999 to December 2000.

RESULTS

Occasional pain and bleeding were referred by the patients with no difference between the two groups. The patients were also equally satisfied with both procedures. No recurrent hemorrhoidal prolapse or stenosis was detected at anorectal exploration and rigid sigmoidoscopy.

CONCLUSION

Both stapled and Milligan-Morgan techniques guarantee satisfactory long-term results. Larger studies are needed to assess the durability of stapled hemorrhoidectomy.