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

Randomized Controlled Trial to Compare Stapled Hemorrhoidopexy Plus Ligation Anopexy With Stapled Hemorrhoidopexy for Managing Grade III and IV Hemorrhoidal Disease

BACKGROUND

Despite the benefits of the stapled hemorrhoidopexy in the short term, management of prolapsing hemorrhoids, the long-term results are still insufficient regarding recurrent prolapse and patient satisfaction. The current study investigates the addition of ligation anopexy to stapled hemorrhoidopexy.

OBJECTIVE

Valuation of adding ligation anopexy to stapled hemorrhoidopexy in improving short-term and long-term results in the treatment of grade III and IV hemorrhoids.

DATA SOURCES

Between January 2018 and January 2020, we recruited 124 patients with grade III and IV hemorrhoids at Alexandria Main University Hospital.

STUDY SELECTION

Randomized controlled trial.

INTERVENTIONS

One hundred twenty-four patients were blindly randomly assigned to 2 equal groups: stapled hemorrhoidopexy (group I) and stapled hemorrhoidopexy plus ligation anopexy (group II).

MAIN OUTCOME MEASURES

Recurrence of hemorrhoids and patient satisfaction after a follow-up period of at least 2 years.

RESULTS

The average operating time was noticeably less in the stapled hemorrhoidopexy group. Postoperative pain, analgesia requirement, hemorrhoid symptoms score, return to work, complications rate, and quality of life 1 month after surgery were similar between groups. Following a mean follow-up of 36 months (interval, 24-47), in group I, 10 patients (16%) reported recurrent external swelling and/or prolapse compared to 3 patients (5%) in group II ( p  = 0.0368). Five patients in group I required redo surgery, whereas no patients required redo surgery in group II. Long-term patient satisfaction was significantly better in group II.

LIMITATIONS

It was a single-center experience, so longer follow-up was needed.

CONCLUSIONS

Stapled hemorrhoidopexy and stapled hemorrhoidopexy plus ligation anopexy were similar in short-term results with regard to complications rate, hemorrhoids symptoms score, return to work, and quality of life. Long-term results were significantly better with regard to recurrence of external swelling and/or prolapse and patient satisfaction after stapled hemorrhoidopexy plus ligation anopexy. See Video Abstract .

TRIAL REGISTRATION NUMBER

Pan African Clinical Trials Registry identifier PACTR20180100293130.

ECA PARA COMPARAR LA HEMORROIDOPEXIA CON GRAPAS MS ANOPEXIA POR LIGADURA CON LA HEMORROIDOPEXIA CON GRAPAS PARA EL TRATAMIENTO DE LA ENFERMEDAD HEMORROIDAL DE GRADO III Y IV

ANTECEDENTES:A pesar de los beneficios de la hemorroidopexia con grapas a corto plazo, el manejo de las hemorroides prolapsadas, los resultados a largo plazo aún son insuficientes en cuanto al prolapso recurrente y la satisfacción del paciente, por lo que en nuestro estudio actual agregamos anopexia por ligadura a la hemorroidopexia con grapas.OBJETIVO:Valoración de añadir anopexia por ligadura a la hemorroidopexia con grapas para mejorar los resultados a corto y largo plazo en el tratamiento de las hemorroides grado III-IV.FUENTES DE DATOS:Entre enero de 2018 y enero de 2020 reclutamos a 124 pacientes con hemorroides de grado III-IV en el hospital universitario principal de Alexandria.SELECCIÓN DEL ESTUDIO:Ensayo controlado aleatorio PACTR201801002931307.INTERVENCIÓN(S):124 pacientes fueron asignados al azar de forma ciega a dos grupos iguales, hemorroidopexia con grapas (grupo I) y hemorroidopexia con grapas más anopexia por ligadura (grupo II).PRINCIPALES MEDIDAS DE RESULTADO:Recurrencia de hemorroides y satisfacción del paciente después de un período de seguimiento de al menos dos años.RESULTADOS:El tiempo operatorio promedio fue notablemente menor en el grupo de hemorroidopexia con grapas. Mientras tanto, el dolor posoperatorio, la necesidad de analgesia, la puntuación de los síntomas de hemorroides, el regreso al trabajo, la tasa de complicaciones y la calidad de vida un mes después de la cirugía fueron similares. Después de un seguimiento medio de 36 meses (intervalo: 24-47), el Grupo I, 10 pacientes (16%) se quejaron de inflamación externa recurrente y/o prolapso en comparación con 3 pacientes (5%) en el Grupo II ( p = 0,0368) que requiere rehacer la cirugía. No fue necesaria una nueva cirugía en el grupo II; además, la satisfacción del paciente a largo plazo fue significativamente mejor en el grupo II.LIMITACIONES:Se necesita un seguimiento más prolongado y experiencia en un solo centro.CONCLUSIONES:La hemorroidopexia con grapas comparada con la hemorroidopexia con grapas más anopexia por ligadura fue similar en resultados a corto plazo en cuanto a tasa de complicaciones, puntuación de síntomas de hemorroides, regreso al trabajo y calidad de vida. Los resultados a largo plazo fueron significativamente mejores en cuanto a la recurrencia de la inflamación externa y/o el prolapso y la satisfacción del paciente después de la hemorroidopexia con grapas más anopexia por ligadura. (Traducción-Dr. Mauricio Santamaria ).

Comparison between stapled hemorrhoidopexy and harmonic scalpel hemorrhoidectomy in the management of third- and fourth-degree piles: a randomized clinical trial

BACKGROUND

This study compared the results of stapled hemorrhoidopexy (SH) and harmonic scalpel hemorrhoidectomy (HSH) in the management of grade III and grade IV piles regarding the time of the procedure, postoperative pain, patient satisfaction, wound infection, bleeding, incontinence, and recurrence within 1 year.

PATIENTS AND METHODS

This was a single-blind, prospective, randomized, controlled, single-center trial conducted from January to December 2022 that included 50 (68.75%) male and 20 (31.25%) female patients with third- and fourth-degree piles.

RESULTS

The patients were divided into two groups of 35 patients each. Group I underwent SH and group II underwent HSH. The mean age of group I was 42.94 years and of group II, 42.20 years. The mean time of the procedure was 24.42 min ± 2.367 for SH and 31.48 min ± 2.21 for HSH. Postoperative pain in group I was lower than in group II during the first 2 weeks, but there was persistent mild pain in most patients in group I at the 2‑week follow-up. In group II there was significant improvement in pain after 2 weeks, with higher patient satisfaction. Wound infection was detected in 3 (5%) patients in group I and no patients in group II (p = 0.077). Postoperative bleeding occurred in 4 (11.4%) patients in group I in the form of spotting after defecation only during the first postoperative month; no bleeding was detected in group II (p = 0.039). There were 3 (15%) cases of flatus incontinence but after taking a detailed history these were found to be cases of urgency to defecate rather than incontinence. There were 7 (20%) cases of recurrence at the 1‑year follow-up in group I and 1 (2.9%) case in group II (p = 0.024).

CONCLUSION

Compared with SH, HSH was safer, easier, and associated with a lower incidence of recurrence after 1 year and with higher patient satisfaction.

Analgesic effect of subcutaneous injection of different concentrations of methylene blue after hemorrhoidectomy: A retrospective study

Objective

Subcutaneous injection of methylene blue around the anus may help reduce postoperative pain. However, the concentration of methylene blue is still controversial. Therefore, Our study aims to investigate the efficacy and safety of different methylene blue injected concentrations subcutaneously in pain treatment after hemorrhoidectomy.

Methods

A total of 180 consecutive patients with grade III or IV hemorrhoids from March 2020 to December 2021 were reviewed. All patients underwent hemorrhoidectomy under spinal anesthesia and were divided into three groups. Group A received subcutaneous injection of 0.1% methylene blue after hemorrhoidectomy, group B received subcutaneous injection of 0.2% methylene blue, and Group C did not received subcutaneous injection of methylene blue. The primary outcome measures were the visual analog scale (VAS) pain score on postoperative days 1, 2, 3, 7, 14, and total analgesic consumption within 14 days. Secondary outcomes were complications after hemorrhoidectomy, including acute urinary retention, secondary bleeding, perianal incision edema, and perianal skin infection, and the Wexner scores used to assess the level of anal incontinence at one and three months after surgery.

Results

There was no significant difference among three groups in sex, age, course of the disease, hemorrhoid grade and the number of incisions, and there was no significant difference in the volume of methylene blue injected between group A and group B. The VAS pain score and total analgesics consumption within 14 days in group A and group B were significantly lower than those in group C, but the differences between group A and group B were not statistically significant. The Wexner scores of group B were significantly higher than those of group A and group C one month after the operation, but the differences between group A and group C were not statistically significant. In addition, the Wexner score among three groups decreased to zero at three months after operation. There was no significant difference in the incidence of other complications among three groups.

Conclusion

The perianal injection of 0.1% methylene blue and 0.2% methylene blue have a similar analgesic effect in pain treatment after hemorrhoidectomy, but 0.1% methylene blue has higher safety.

Long-term outcomes of high-volume stapled hemorroidopexy to treat symptomatic hemorrhoidal disease

PURPOSE

The study aimed to assess the long-term results of the stapled hemorrhoidopexy (SH) using high-volume devices equipped with innovative technology, evaluating recurrence rate, complications rate, and patients' satisfaction.

METHODS

All the patients who underwent SH using high-volume devices (TST Starr plus, Touchstone International Medical Science Corp., Ltd.) for II to IV symptomatic hemorrhoidal disease from November 2012 to December 2014 were enrolled. Between December 2019 and January 2020, all of them were phone called to come to undergo a proctological reevaluation and asked to fill some questionnaires about hemorrhoidal prolapse recurrence, symptoms recurrence, and surgery satisfaction.

RESULTS

Fifty-nine patients with a mean age of 47 years completely answered the questionnaires. Twenty-two of them accepted to come to undergo a proctological reevaluation while 27 preferred to answer only by phone due to their referred wellbeing. The median follow-up was 70.5 months (range, 60-84 months). The recurrence rate was 5.1% with a mean satisfaction level after surgery was 9.1 (range, 0-10) and 84.7% of patients whose satisfaction scored ≥8. The mean value of Cleveland Global Quality of Life assessment was 0.79 (range, 0.71-0.93). There were no cases of new onset of impaired anal continence after surgery.

CONCLUSION

The new generation high-volume devices to perform SH resulted to be safe and effective for II to IV degree hemorrhoidal prolapse leading to a lower long-term recurrence rate with an evident reduction of postoperative complications in comparison with the low-volume SH.

Correlation Between Poor Defecation Habits and Postoperative Hemorrhoid Recurrence

Background

The relationship between hemorrhoid recurrence and poor defecation habits is poorly understood. This study aimed to analyze the effects of poor defecation habits on postoperative hemorrhoid recurrence.

Materials and Method

We performed a retrospective study on 1,162 consecutive patients who underwent a surgical procedure for hemorrhoids at the Sixth Affiliated Hospital of Sun Yat-Sen University from December 2016 to May 2020. All patients were followed for 12 months post-operatively. Patients were monitored for disease recurrence. Patient defecation habits were assessed using an obstructive defecation syndrome (ODS) score.

Results

Patients with a score of 0–4 had a mild defecation disorder, 5–8 a moderate defecation disorder, and 9 or more ODS. Of the 1,162 patients, 1,144 (98.45%) had a mild defecation disorder, 13 (1.12%) had a moderate defecation disorder, and 9 (0.43%) had ODS. Older patients were significantly more likely to have worse defecation habits (P < 0.001). A higher ODS score correlated with a higher maximum anal squeeze pressure (P = 0.07) and a more severe inability for the anus to relax during simulated evacuation (P = 0.002). The maximum rectum threshold was also found to be the highest in ODS patients (P = 0.010). The proportion of Procedure for prolapsing hemorrhoids (PPH) was the highest in the moderate defecation disorder group (53.85), followed by the ODS group (40.00) and the mild defecation disorder group (P = 0.023). Recurrence occurred in 5.51% of patients in the mild defecation disorder group, 38.46% of the moderate defecation disorder group, and 60% of the ODS group (P < 0.001). Multivariate analysis confirmed a higher ODS score (P < 0.001) was an independent predictor of recurrence. Furthermore, patients who occasionally exercised (P = 0.01) and patients who exercised regularly (P = 0.021) were less likely to have a recurrence.

Conclusion

Patients with unresolved defecation disorders are more likely to have their hemorrhoids recur and are unlikely to be satisfied with surgical management.

LigaSure hemorrhoidectomy versus the procedure for prolapse and hemorrhoids: A meta-analysis of randomized controlled trials

BACKGROUND

LigaSure hemorrhoidectomy and the procedure for prolapse and hemorrhoids (PPH) are both relatively new treatments for managing symptomatic hemorrhoids. This review aimed to evaluate and compare their short-term outcomes.

METHODS

We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and the China National Knowledge Infrastructure database for randomized controlled trials comparing the LigaSure procedure and PPH published in any language from 1998 to October 2013.

RESULTS

A total of 5 studies involving 397 participants were included in this review. Pooled analysis showed that the LigaSure procedure was associated with significantly lower recurrence rate [relative risk (RR) = 0.21, 95% confidence interval (CI): 0.06 to 0.72, P = .01] and significantly shorter operating time [mean difference (MD) = -6.39, 95% CI: -7.68 to -5.10, P < .001]. The analysis showed no significant difference in postoperative pain between the two techniques (MD = 0.55, 95% CI: -0.15 to 1.25, P = .12] or in time off work or away from normal activity [standard MD = 0.13, 95% CI: -1.80 to 2.06, P = .9]. The two techniques did not show significant differences in postoperative complications or other patient-related outcomes (P > .05).

CONCLUSIONS

Our review indicates that both LigaSure hemorrhoidectomy and PPH are safe alternatives for the management of hemorrhoids. Available evidence suggests that the LigaSure technique is associated with shorter operating time and lower hemorrhoid recurrence rate, but these conclusions should be further confirmed in large, multicenter randomized controlled trials with long-term follow-up.

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

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

A new technique of doppler dearterialization for hemorrhoidal disease: arterial detection ligation (ADL)

PURPOSE

We describe the arterial detection ligation (ADL) technique, designed to find arteries at time-appropriate depth for ligating, and report our preliminary results of using this technique to treat patients with the hemorrhoidal disease (HD).

METHODS

The subjects of this retrospective analysis were patients with symptomatic grades 2 or 3 HD. We analyzed the clinical characteristics, postoperative complications, recurrence, and patient satisfaction of the patients treated with ADL.

RESULTS

A total of 75 patients were included in the study (male/female ratio 1.88; mean age 48 ± 19 years; mean BMI 24 ± 3 kg/m²). Thirty-nine patients (52%) did not require hospitalization and were discharged from the day clinic approximately 4 h postoperatively. Four patients (5.3%) suffered tenesmus for about 1 week postoperatively and two (2.7%) suffered temporary rectal bleeding. The mean VAS scores 1 day postoperatively, then at 1 week, 1 month and 1 year were 2.9, 1.5, 0.4, and 0, respectively. At the 1-month follow-up, there was no sign of recurrence and the satisfaction rate was 78.6% (n = 59). At the 1-year follow-up, three patients (4%) had a recurrence and the satisfaction rate was 86.7% (n = 65).

CONCLUSION

Based on our preliminary findings, ADL is an effective technique for treating HD, generally as an outpatient procedure, without serious morbidity. We anticipate that the incidence of tenesmus, which is encountered frequently after other dearterialization methods, will be lower after the ADL technique, which avoids both mass ligation of hemorrhoidal arteries deeper than 12 mm and running a long mucopexy suture line.

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

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

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

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

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

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

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

European Society of ColoProctology: guideline for haemorrhoidal disease

AIM

The goal of this European Society of ColoProctology project was to establish a multidisciplinary, international guideline for haemorrhoidal disease (HD) and to provide guidance on the most effective (surgical) treatment for patients with HD.

METHODS

The development process consisted of six phases. In phase one we defined the scope of the guideline. The patient population included patients with all stages of haemorrhoids. The target group for the guideline was all practitioners treating patients with haemorrhoids and, in addition, healthcare workers and patients who desired information regarding the treatment management of HD. The guideline needed to address both the diagnosis of and the therapeutic modalities for HD. Phase two consisted of the compilation of the guideline development group (GDG). All clinical members needed to have affinity with the diagnosis and treatment of haemorrhoids. Further, attention was paid to the geographical distribution of the clinicians. Each GDG member identified at least one patient in their country who could read English to comment on the draft guideline. In phase three review questions were formulated, using a reversed process, starting with possible recommendations based on the GDG's knowledge. In phase four a literature search was performed in MEDLINE (Ovid), PubMed, Embase (Ovid) and the Cochrane Database of Systematic Reviews. The search was focused on existing systematic reviews addressing each review question, supplemented by other studies published after the time frame covered by the systematic reviews. In phase five data of the included papers were extracted by the surgical resident (RT) and checked by the methodologist (JK) and the GDG. If needed, meta-analysis of the systematic reviews was updated by the surgical resident and the methodologist using Review Manager. During phase six the GDG members decided what recommendations could be made based on the evidence found in the literature using GRADE.

RESULTS

There were six sections: (i) symptoms, diagnosis and classification; (ii) basic treatment; (iii) outpatient procedures; (iv) surgical interventions; (v) special situations; (vi) other surgical techniques. Thirty-four recommendations were formulated.

CONCLUSION

This international, multidisciplinary guideline provides an up to date and evidence based summary of the current knowledge of the management of HD and may serve as a useful guide for patients and clinicians.

Hemorrhoid laser procedure with suture-pexy (HeLPexx): a novel effective procedure to treat hemorrhoidal disease

BACKGROUND

The hemorrhoid laser procedure with suture-pexy (HeLPexx), consisting of Doppler-guided hemorrhoidal dearterialization with laser and the addition of anal mucopexy, is a novel non-excisional procedure to treat hemorrhoids. The aim of the present study was to describe the technique and report the clinical and long-term results.

METHODS

A prospective study was conducted on patients with grade III hemorrhoids who had HeLPexx from January 2012 to February 2018. Pre- and postoperative assessment included a thorough clinical examination, constipation and incontinence scoring systems and a symptom questionnaire which was administered at all patients before surgery and at each follow-up visit to evaluate bleeding, prolapse, manual reduction, discomfort or pain, and impact on quality of life. Each symptom had a score between 0 and 4, (0 indicates no symptoms and 4 indicates daily symptoms). The sum of the score for each symptom constituted the Hemorrhoid Symptom Score. Resolution of symptoms, pain, morbidity, need for further medical and/or surgical therapy were also recorded.

RESULTS

One hundred and seventy consecutive patients with grade III hemorrhoids [74 females; mean age 49.5 years (range 22-79) years] were included. Median length of follow-up was 36 (range 12-72) months. Postoperative morbidity included urinary retention (7 patients, 4.1%), bleeding not requiring transfusion (1 patient, 0.6%) and thrombosis of hemorrhoidal piles (2 patients, 1.2%). The mean postoperative pain VAS score at 1 week postoperatively was 1.8 ± 1.1 (range 0-5) and 12 (7%) patients used pain medications for more than 1 week postoperatively while none of the patients reported any pain by the end of the third week postoperatively. The Hemorrhoid Symptom Score significantly improved from 15.83 ± 3.04 to 1.3 ± 2.4 (p ≤ 0.001) and showed a statistically significant improvement in all items. Recurrent symptoms were reported in 12 patients (7%) who required further treatment. Severe chronic constipation prior to surgery was found to be a predictive factor of failure (p = 0.04).

CONCLUSIONS

HeLPexx appears to be safe and effective for treatment of symptomatic hemorrhoids. Further studies are needed to confirm our results.

Long-Term Results After Stapled Hemorrhoidopexy: A 15-Year Follow-Up

BACKGROUND

The stapled hemorrhoidopexy is reported to have a low recurrence while treating the major hemorrhoidal symptoms of bleeding and prolapse. The aim of this study is to obtain long-term results on the outcome of the stapled hemorrhoidopexy.

METHODS

All patients with a hemorrhoidal disease grade III, who underwent stapled hemorrhoidopexy from May 1999-December 2003, were included. Data collection was based on a standardized telephone interview. In the questionnaire, we recorded information regarding the postoperative recurrence and severity of hemorrhoidal symptoms (defined as bleeding, prolapse, burning, itching and moisture), further hemorrhoidal treatments and functional results (incontinence, fecal urgency and outlet obstruction) as well as patients' satisfaction.

RESULTS

Of the 257 patients, who underwent stapled hemorrhoidopexy, follow-up data were available in 140 patients. In 47.4% of the patients, a recurrence of at least one hemorrhoidal symptom was registered, whereas this recurrence was observed in 47.3% of these patients more than 10 years postoperatively. A surgical re-intervention was necessary in 15.2%. We found a postoperative new incontinence in 15.5%, a fecal urgency in 28.0% and an outlet obstruction in 9.4%. Of all patients, 62.3% were "very satisfied" with the operation.

CONCLUSIONS

The results of the study revealed a relatively high recurrence of hemorrhoidal symptoms after a mean follow-up of 15 years with a high recurrence rate more than 10 years postoperatively. In consideration of not negligible risk of incontinence, fecal urgency and outlet obstruction, the indication for a stapled hemorrhoidopexy should be made well considered. However, patients' satisfaction is very high.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Long-term results after stapled hemorrhoidopexy: a survey study with mean follow-up of 12 years

BACKGROUND

Hemorrhoidal prolapse is a common benign disease. The introduction of circular-stapled hemorrhoidopexy as an alternative to the conventional hemorrhoidectomy led to a new spectrum of postoperative outcomes and complications. The aim of the present study was to evaluate long-term results after stapled hemorrhoidopexy.

METHODS

All the patients who had stapled hemorrhoidopexy using a PPH03 stapler, from January 2003 to December 2005, were retrospectively collected in a dedicated database. Between March and May 2016, all the patients were asked by phone to complete a questionnaire. The study evaluated anatomical recurrence, symptom recurrence and frequency, and satisfaction after surgery. The postoperative complications recorded were hemorrhage, hematoma, urinary retention, anastomotic stenosis, persistent anal pain, tenesmus, and impaired anal continence evaluated also with the Faecal Incontinence Severity Index score.

RESULTS

One hundred and ninety four patients were identified and 171 completed the questionnaire. The mean follow-up was 12 ± 0.8 years (range 11-13 years). Anatomical self-reported prolapse recurrence was 40.9% (n = 70). In 75.6% (n = 129) of patients, the severity and frequency of symptoms improved. The overall complication rate was 56.7% (n = 40) with a serious adverse event rate of 8.7% (n = 15). The overall tenesmus rate was 38.2% (n = 65) and the overall impaired continence rate was 39.1% (n = 67). Medical therapy was still required occasionally by 40.3% (n = 69) of the patients and 9.3% (n = 16) of the patients underwent surgery for recurrence. Patient satisfaction rate was good (≥ 3 on a scale of 1 to 5) in 81.2% (n = 139) of cases.

CONCLUSIONS

The study showed that stapled hemorrhoidopexy using the first-generation devices is safe and feasible but associated with a high recurrence and incontinence rate. More stringent selection criteria in association with the use of large volume devices can lead to better results in the future.

Stapled Hemorrhoidopexy: Results at 10-Year Follow-up

BACKGROUND

Despite the advantages of stapled hemorrhoidopexy reported in the literature in terms of postoperative pain, hospital stay, and duration of convalescence, it was described to have a higher recurrence rate compared with conventional hemorrhoidectomy.

OBJECTIVE

The aim of this study was to evaluate clinical outcomes and patient satisfaction after stapled hemorrhoidopexy at 10-year follow-up.

DESIGN

This was a retrospective cohort analysis conducted on prospectively collected data.

SETTINGS

The study was conducted at a single tertiary care center.

PATIENTS

Eighty-six consecutive patients treated with stapled hemorrhoidopexy for grade 3 hemorrhoidal prolapse between January and December 2006 were included.

MAIN OUTCOME MEASURES

Patients satisfaction and recurrence rates were measured.

RESULTS

Eighty-six patients (45 men and 41 women; median age, 49 y (range, 31-74 y)) underwent stapled hemorrhoidopexy. Eight patients had urinary retention during the immediate postoperative period, and 2 patients required a reoperation for suture line bleeding. The median hospital stay was 12 hours (range, 12-96 h). No suture line dehiscence, rectovaginal fistula, pelvic sepsis, anal abscess, or anal stenosis was recorded during the follow-up. Seventy-seven patients (90%) completed the expected follow-up, with a median duration of 119.0 months (range 115.4-121.8 mo). Among them, 30 patients (39%) experienced a recurrent hemorrhoidal prolapse, 8 of whom needed a reoperation. Thirty-four patients (44%) reported urge to defecate with a median visual analog scale of 1 (range, 1-7). Six patients (8%) reported gas leakage at the last follow-up visit, whereas no liquid or solid stool leakage was recorded. Satisfaction rate at 10-year follow-up was 68%.

LIMITATIONS

The study was limited by its small sample size and lack of a control group.

CONCLUSIONS

The high recurrence rate and low patient satisfaction rate showed that stapled hemorrhoidopexy reduces its efficacy in the long-term. See Video Abstract at http://links.lww.com/DCR/A510.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A pragmatic multicentre randomised controlled trial comparing stapled haemorrhoidopexy with traditional excisional surgery for haemorrhoidal disease: the eTHoS study

BACKGROUND

Haemorrhoids are a benign anorectal condition and are highly prevalent in the UK population. Treatments involve clinic-based procedures and surgery. The surgical procedures available include stapled haemorrhoidopexy (SH) and traditional haemorrhoidectomy (TH), and over 25,000 operations are performed for haemorrhoids annually in the UK. The disease is therefore important both to patients and to health service commissioners. Debate remains as to which of these surgical procedures is the most clinically effective and cost-effective.

OBJECTIVE

The aim of this study was to compare the clinical effectiveness and cost-effectiveness of SH with that of TH.

DESIGN

A large, open two-arm parallel-group pragmatic multicentre randomised controlled trial involving 32 UK hospitals and a within-trial cost-benefit analysis. A discrete choice experiment was conducted to estimate benefits (willingness to pay).

PARTICIPANTS

Patients with grades II-IV haemorrhoids who had not previously undergone SH or TH were included in the study.

INTERVENTIONS

Participants were randomised to receive either SH or TH. Randomisation was minimised at 1 : 1, in accordance with baseline EuroQol-5 Dimensions, three-level version (EQ-5D-3L) score, haemorrhoid grade, sex and centre, via an automated system.

MAIN OUTCOME MEASURES

The primary outcome was area under the quality-of-life curve measured using the EQ-5D-3L descriptive system over 24 months, and the primary economic outcome was the incremental cost-effectiveness ratio. Secondary outcomes included disease-specific quality of life, recurrence, complications, further interventions and costs.

RESULTS

Between January 2011 and August 2014, 777 patients were randomised (389 to receive SH and 388 to receive TH). There were 774 participants included in the analysis as a result of one post-randomisation exclusion in the SH arm and two in the TH arm. SH was less painful than TH in the short term. Surgical complications were similar in both arms. EQ-5D-3L score was higher for the SH arm in the first 6 weeks after surgery, but over 24 months the TH group had significantly better EQ-5D-3L scores (-0.073, 95% confidence interval -0.140 to -0.006; p = 0.0342). Symptoms and further interventions were significantly fewer in the TH arm at 24 months. Continence was better in the TH arm and tenesmus occurred less frequently. The number of serious adverse events reported was 24 out of 337 (7.1%) for participants who received SH and 33 out of 352 (9.4%) for those who received TH. There were two deaths in the SH arm, both unrelated to the eTHoS (either Traditional Haemorrhoidectomy or Stapled haemorrhoidopexy for haemorrhoidal disease) study. Patient preference did not seem to influence the treatment difference. SH was dominated by TH as it cost more and was less effective. The net benefit for the TH arm was higher than that for the SH arm.

LIMITATIONS

Neither the participants nor the assessors were masked to treatment assignment and final recruitment was slightly short of the total target of 800. There were also substantial missing follow-up data.

CONCLUSIONS

While patients who received SH had less short-term pain, after 6 weeks, recurrence rates, symptoms, re-interventions and quality-of-life measures all favoured TH. In addition, TH is cheaper. As part of a tailored management plan for haemorrhoids, TH should be considered over SH as the surgical treatment of choice for haemorrhoids refractory to clinic-based interventions.

FUTURE WORK

Perform an updated meta-analysis incorporating recently conducted European trials [eTHoS, HubBLe (haemorrhoidal artery ligation versus rubber band ligation for the management of symptomatic second-degree and third-degree haemorrhoids) and LingaLongo (Cost-effectiveness of New Surgical Treatments for Haemorrhoidal Disease)].

TRIAL REGISTRATION

Current Controlled Trials ISRCTN80061723.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 70. See the NIHR Journals Library website for further project information.

LONG TERM RESULTS AFTER STAPLED HEMORRHOIDOPEXY ALONE AND COMPLEMENTED BY EXCISIONAL HEMORRHOIDECTOMY: A RETROSPECTIVE COHORT STUDY

Background:

Stapled hemorrhoidopexy is associated with less postoperative pain and faster recovery. However, it may be associated with a greater risk of symptomatic recurrence. We hypothesized that undertaking a limited surgical excision of hemorrhoid disease after stapling may be a valid approach for selected patients.

Aim:

To compare long-term results after stapled hemorrhoidopexy with and without complementation with closed excisional technique.

Method:

In a retrospective uni-institutional cohort study, sixty-five (29 men) patients underwent stapled hemorrhoidopexy and 21 (13 men) underwent stapled hemorrhoidopexy with excision. The same surgeons operated on all cases. Patients underwent stapled hemorrhoidectomy associated with excisional surgery if symptoms attributable to external hemorrhoid piles were observed preoperatively, or if residual prolapse or bulky external disease was observed after the firing of the stapler. A closed excisional diathermy hemorrhoidectomy without vascular ligation was utilized in all complemented cases. All clinical variables were obtained from a questionnaire evaluation obtained through e-mail, telephone interview, or office follow-up.

Results:

The median duration of postoperative follow-up was 48.5 (6-40) months. Patients with grades 3 and 4 hemorrhoid disease were operated on more frequently using stapled hemorrhoidopexy complemented with excisional technique (95.2% vs. 55.4%, p=0.001). Regarding respectively stapled hemorrhoidopexy and stapled hemorrhoidopexy complemented with excision, there was no difference between the techniques in relation to symptom recurrence (43% and 33%, p=0.45) and median interval between surgery and symptom recurrence (30 (8-84) and 38.8 (8-65) months, p=0.80). Eight (12.3%) patients were re-operated after stapled hemorrhoidopexy and 2 (9.6%), after hemorrhoidopexy with excision (p=0.78). Patient distribution in both groups according to the degree of postoperative satisfaction was similar (p=0.97).

Conclusion:

Stapled hemorrhoidopexy combined with an excisional technique was effective for more advanced hemorrhoid disease. The combination may have prevented symptomatic recurrence associated to stapled hemorrhoidopexy alone.

Comparison of stapled haemorrhoidopexy with traditional excisional surgery for haemorrhoidal disease (eTHoS): a pragmatic, multicentre, randomised controlled trial

BACKGROUND

Two commonly performed surgical interventions are available for severe (grade II-IV) haemorrhoids; traditional excisional surgery and stapled haemorrhoidopexy. Uncertainty exists as to which is most effective. The eTHoS trial was designed to establish the clinical effectiveness and cost-effectiveness of stapled haemorrhoidopexy compared with traditional excisional surgery.

METHODS

The eTHoS trial was a large, open-label, multicentre, parallel-group, pragmatic randomised controlled trial done in adult participants (aged 18 years or older) referred to hospital for surgical treatment for grade II-IV haemorrhoids. Participants were randomly assigned (1:1) to receive either traditional excisional surgery or stapled haemorrhoidopexy. Randomisation was minimised according to baseline EuroQol 5 dimensions 3 level score (EQ-5D-3L), haemorrhoid grade, sex, and centre with an automated system to stapled haemorrhoidopexy or traditional excisional surgery. The primary outcome was area under the quality of life curve (AUC) measured with the EQ-5D-3L descriptive system over 24 months, assessed according to the randomised groups. The primary outcome measure was analysed using linear regression with adjustment for the minimisation variables. This trial is registered with the ISRCTN registry, number ISRCTN80061723.

FINDINGS

Between Jan 13, 2011, and Aug 1, 2014, 777 patients were randomised (389 to receive stapled haemorrhoidopexy and 388 to receive traditional excisional surgery). Stapled haemorrhoidopexy was less painful than traditional excisional surgery in the short term and surgical complication rates were similar between groups. The EQ-5D-3L AUC score was higher in the traditional excisional surgery group than the stapled haemorrhoidopexy group over 24 months; mean difference -0·073 (95% CI -0·140 to -0·006; p=0·0342). EQ-5D-3L was higher for stapled haemorrhoidopexy in the first 6 weeks after surgery, the traditional excisional surgery group had significantly better quality of life scores than the stapled haemorrhoidopexy group. 24 (7%) of 338 participants who received stapled haemorrhoidopexy and 33 (9%) of 352 participants who received traditional excisional surgery had serious adverse events.

INTERPRETATION

As part of a tailored management plan for haemorrhoids, traditional excisional surgery should be considered over stapled haemorrhoidopexy as the surgical treatment of choice.

FUNDING

National Institute for Health Research Health Technology Assessment programme.

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.

High-Volume Transanal Surgery with CPH34 HV for the Treatment of III-IV Degree Haemorrhoids: Final Short-Term Results of an Italian Multicenter Clinical Study

The clinical chart of 621 patients with III-IV haemorrhoids undergoing Stapled Hemorrhoidopexy (SH) with CPH34 HV in 2012–2014 was consecutively reviewed to assess its safety and efficacy after at least 12 months of follow-up. Mean volume of prolapsectomy was significantly higher (13.0 mL; SD, 1.4) in larger prolapse (9.3 mL; SD, 1.2) (p < 0.001). Residual or recurrent haemorrhoids occurred in 11 of 621 patients (1.8%) and in 12 of 581 patients (1.9%), respectively. Relapse was correlated with higher preoperative Constipation Scoring System (CSS) (p = 0.000), Pescatori's degree (p = 0.000), Goligher's grade (p = 0.003), prolapse exceeding half of the length of the Circular Anal Dilator (CAD) (p = 0.000), and higher volume of prolapsectomy (p = 0.000). At regression analysis, only the preoperative CSS, Pescatori's degree, Goligher's grade, and volume of resection were significantly predictive of relapse. A high level of satisfaction (VAS = 8.6; SD, 1.0) coupled with a reduction of 12-month CSS (Δ preoperative CSS/12 mo CSS = 3.4, SD, 2.0; p < 0.001) was observed. The wider prolapsectomy achievable with CPH34 HV determined an overall 3.7% relapse rate in patients with high prevalence of large internal rectal prolapse, coupled with high satisfaction index, significant reduction of CSS, and very low complication rates.

HAL-RAR (Doppler guided haemorrhoid artery ligation with recto-anal repair) is a safe and effective procedure for haemorrhoids. Results of a prospective study after two-years follow-up

PURPOSE

To analyse prospectively results of HAL-RAR technique by evaluating pain, perioperative complications and clinical outcome after two years followup.

METHODS

A prospective study design including 30 consecutive patients with haemorrhoids grade III-IV treated from June 2012. After discharge, patients received a specific questionnaire to record postoperative pain, delayed complications, evolution/disappearance of the symptoms that led to the surgical intervention (bleeding, prolapse, itching, pain and soiling). A visual analog scale (VAS) was used to measure pain. Outpatient follow-up was carried out at 7 days, and 1, 6 and 12 months and annually thereafter. Pre, intra and postoperative data (including physical examination) had been recorded prospectively.

RESULTS

The median operating time (range) was 40 (26-60) minutes. Average hospital stay (range) was 11 (3-25) hours. No postoperative complications were observed in 29 cases (96.6%). Median follow-up was 26 (12-36) months. All the patients attended the follow-up. Mean postoperative pain was VAS = 1.7 on the seventh day and it was practically non-existent (VAS = 0.7) 1 month after the procedure. 87.5% of patients confirmed complete relief of symptoms after 30 days and 93% of patients feel free of symptoms 6 months after the procedure. No patient has experienced late complications as dyschezia, urgency, soiling or faecal incontinence. After 24 months follow-up, recurrence of bleeding and prolapse was observed in only 1 patient; 93% of patients have considered results of HAL-RAR as very good or excellent.

CONCLUSION

HAL-RAR is safe and almost painless technique and it has very good results in the control of haemorrhoidal symptoms. This procedure should be considered as an effective first treatment option for haemorrhoids.

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Proctitis after stapled hemorrhoidopexy is an underestimated complication of a widely used surgical procedure: a retrospective observational cohort study in 129 patients

Background

Hemorrhoidal disease is highly prevalent in the western world. Stapled hemorrhoidopexy also known as the procedure for prolapsed hemorrhoids (pph) has been shown to be superior to conventional hemorrhoidectomy with regard to postoperative pain, length of hospital stay and early return to work. Proctitis following stapled hemorrhoidopexy has not been reported previously. Herein, we report our experience with proctitis in patients following stapled hemorrhoidopexy and question if proctitis could be a complication of stapled hemorrhoidopexy.

Materials and methods

A retrospective analysis of the data of patients undergoing stapled hemorrhoidopexy with the PPH03 in the coloproctology unit of the department of surgery of a primary care hospital in Germany within a 5-year period was performed. All cases were managed and followed up by a single attending surgeon with expertise in coloproctology.

Results

129 patients were included for analysis including 21 cases with grade 2, 103 cases of grade 3 and 5 cases of grade 4 hemorrhoids. The median duration of surgery was 20 min. 17 complications including two recurrences were recorded. Post-pph proctitis was recorded in 14 cases (10.9 %). Post-pph proctitis was not associated with gender, extent of hemorrhoidal disease, BMI and ASA (p >0.05). All cases recovered within 4 weeks following management with nonsteroidal anti-inflammatory drugs and suppositories.

Conclusion

Proctitis could be a complication of stapled hemorrhoidopexy with a good response to conservative treatment with suppositories.

Stapled haemorrhoidopexy: is it time to move on?

Stapled haemorrhoidectomy was proposed as an 'ideal' solution for symptomatic haemorrhoids, with minimal postoperative pain, no perianal wound requiring postoperative wound care and a relatively short operative time. Some randomised controlled trials and reviews confirmed these findings, claiming that stapled haemorrhoidopexy is the most effective and safe procedure for haemorrhoids. However, there are increasing number of publications highlighting that the technique is associated with serious and life threatening complications. Maybe it is now the time to accept that stapled haemorrhoidopexy has done its role in directing our attention to the fact that modern surgical treatment of haemorrhoids should avoid excision of anorectal skin but should instead aim at treatment intervention above the dentate line.

Clinical application of procedure for prolapse and hemorrhoids

As the sliding anal cushion theory is widely accepted, the procedure for prolapse and hemorrhoids (PPH) has been applied all over the world. PPH mainly involves restoring the normal anatomy of the anal canal by circular excision of the mucosa above the hemorrhoids. Therefore, the blood supply is partially blocked so that hemorrhoids will gradually shrink. PPH has many advantages such as rapid rehabilitation, minimal invasiveness, and good short-term outcome (early resumption, less rectal bleeding and postoperative pain). However, many retrospective studies and meta-analyses indicate that, compared with the traditional surgery, PPH still has a number of deficiencies, including relatively high costs, high rates of relapse in a long term and so on. This review discusses the strategies, postoperative complications and clinical application of PPH.

Local anaesthetic infiltration for the rubber band ligation of early symptomatic haemorrhoids: a systematic review and meta-analysis

The objective of this article is to systematically analyse the randomized, controlled trials evaluating the effectiveness of local anaesthetic infiltration prior to the rubber band ligation of early symptomatic haemorrhoids. Published randomized, controlled trials comparing the use of local anaesthetic (LA) versus no-local anaesthetic (NLA) for the rubber band ligation of early symptomatic haemorrhoids were analysed using RevMan®, and the combined outcomes were expressed as odds ratios (OR) and standardized mean difference (SMD). Four randomized, controlled trials evaluating 387 patients were retrieved from the standard electronic databases. The risk of treatment failure (OR 0.44; 95% CI 0.07, 2.79; z = 0.87; p = 0.39) and post-procedure complications (OR 0.48; 95% CI 0.08, 2.76; z = 0.83; p = 0.41) was similar between two techniques. However, the post-procedure pain score (SMD -5.19; 95% CI -9.08, -1.30; z = 2.62; p < 0.009) was significantly lower in the group of patients undergoing rubber band ligation of haemorrhoids under local anaesthetic injection. The use of LA appears to have clinically measurable advantages over NLA in the rubber band ligation of early symptomatic haemorrhoids to lessen post-procedure pain.

Surgical treatment of hemorrhoids: a critical appraisal of the current options

INTRODUCTION

Surgical treatment of hemorrhoids is still a dilemma. New techniques have been developed leading to a lower rate of postoperative pain; however, they are associated with a greater likelihood of recurrence.

AIM

To review current indications as well as the results and complications of the main techniques currently used in the surgical treatment of hemorrhoidal disease.

METHODS

A systematic search of the published data on the options for treatment of hemorrhoids up to December 2012 was conducted using Medline/PubMed, Cochrane, and UpToDate.

RESULTS

Currently available surgical treatment options include procedure for prolapse and hemorrhoids (PPH), transanal hemorrhoidal dearterialization (THD), and conventional hemorrhoidectomy techniques. Excisional techniques showed similar results regarding pain, time to return to normal activities, and complication rates. PPH and THD were associated with less postoperative pain and lower complication rates; however, both had higher postoperative recurrence rates.

CONCLUSION

Conventional surgical techniques yield better long-term results. Despite good results in the immediate postoperative period, PPH and THD have not shown consistent long-term favorable results.

Recent advances in the management of hemorrhoids

Hemorrhoids are considered one of the most common anorectal diseases with a prevalence of 4.4% up to 36.4% of the general population, and a peak incidence between 45 and 65 years. Hemorrhoidal disease presents with a prolapsed lump, painless bleeding, discomfort, discharge, hygiene problems, soiling, and pruritus. Sliding anal canal lining theory is the most accepted theory as a cause of hemorrhoidal disease; however, it is also associated with hyper-vascularity, and, recently, with several enzymes or mediators involved in the disintegration of the tissues supporting the anal cushions, such as matrix metalloproteinase. A comprehensive search in published English-language literature till 2013 involving hemorrhoids was performed to construct this review article, which discusses advances in the management of hemorrhoids. This includes conservative treatment (life style modification, oral medications, and topical treatment), office procedures (rubber band ligation, injection sclerotherapy, infrared and radiofrequency coagulation, bipolar diathermy and direct-current electrotherapy, cryosurgery, and laser therapy), as well as surgical procedures including diathermy hemorrhoidectomy, LigaSure hemorrhoidectomy, Harmonic scalpel hemorrhoidectomy, hemorrhoidal artery ligation, stapled hemorrhoidopexy (SH), and double SH. Results, merits and demerits of the different modalities of treatment of hemorrhoids are presented, in addition to the cost of the recent innovations.

A pragmatic, multicentre, randomised controlled trial comparing stapled haemorrhoidopexy to traditional excisional surgery for haemorrhoidal disease (eTHoS): study protocol for a randomised controlled trial

BACKGROUND

Current interventions for haemorrhoidal disease include traditional haemorrhoidectomy (TH) and stapled haemorrhoidopexy (SH) surgery. However, uncertainty remains as to how they compare from a clinical, quality of life (QoL) and economic perspective. The study is therefore designed to determine whether SH is more effective and more cost-effective, compared with TH.

METHODS/DESIGN

eTHoS (either Traditional Haemorrhoidectomy or Stapled Haemorrhoidopexy for Haemorrhoidal Disease) is a pragmatic, multicentre, randomised controlled trial. Currently, 29 secondary care centres are open to recruitment. Patients, aged 18 year or older, with circumferential haemorrhoids grade II to IV, are eligible to take part. The primary clinical and economic outcomes are QoL profile (area under the curve derived from the EuroQol Group's 5 Dimension Health Status Questionnaire (EQ-5D) at all assessment points) and incremental cost per quality adjusted life year (QALY) based on the responses to the EQ-5D at 24 months. The secondary outcomes include a comparison of the SF-36 scores, pain and symptoms sub-domains, disease recurrence, complication rates and direct and indirect costs to the National Health Service (NHS). A sample size of n =338 per group has been calculated to provide 90% power to detect a difference in the mean area under the curve (AUC) of 0.25 standard deviations derived from EQ-5D score measurements, with a two-sided significance level of 5%. Allowing for non-response, 400 participants will be randomised per group. Randomisation will utilise a minimisation algorithm that incorporates centre, grade of haemorrhoidal disease, baseline EQ-5D score and gender. Blinding of participants and outcome assessors is not attempted.

DISCUSSION

This is one of the largest trials of its kind. In the United Kingdom alone, 29,000 operations for haemorrhoidal disease are done annually. The trial is therefore designed to give robust evidence on which clinicians and health service managers can base management decisions and, more importantly, patients can make informed choices.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN80061723 (assigned 8 March 2010).

ACG clinical guideline: management of benign anorectal disorders

These guidelines summarize the definitions, diagnostic criteria, differential diagnoses, and treatments of a group of benign disorders of anorectal function and/or structure. Disorders of function include defecation disorders, fecal incontinence, and proctalgia syndromes, whereas disorders of structure include anal fissure and hemorrhoids. Each section reviews the definitions, epidemiology and/or pathophysiology, diagnostic assessment, and treatment recommendations of each entity. These recommendations reflect a comprehensive search of all relevant topics of pertinent English language articles in PubMed, Ovid Medline, and the National Library of Medicine from 1966 to 2013 using appropriate terms for each subject. Recommendations for anal fissure and hemorrhoids lean heavily on adaptation from the American Society of Colon and Rectal Surgeons Practice Parameters from the most recent published guidelines in 2010 and 2011 and supplemented with subsequent publications through 2013. We used systematic reviews and meta-analyses when available, and this was supplemented by review of published clinical trials.

Comparison of transanal haemorrhoidal dearterialisation and stapled haemorrhoidopexy in management of haemorrhoidal disease: a retrospective study and literature review

BACKGROUND

The aim of this study was to evaluate and compare transanal haemorrhoidal dearterialisation (THD) and stapled haemorrhoidopexy [also called procedure for prolapsed haemorrhoids (PPH)] in the management of haemorrhoidal disease, in terms of short-term outcomes and efficacy.

METHODS

Patients presenting with symptomatic haemorrhoids were treated with THD. Patient demographics, pre-operative data, post-operative pain scores, complications, recurrence, and patient satisfaction scores were evaluated and recorded. Patients with acute thrombosed haemorrhoids, external haemorrhoids only, or other concomitant anal diseases were excluded. These data were compared with the historical data of PPH.

RESULTS

Forty consecutive patients underwent THD from February 2012 to July 2013 and were compared to 37 patients who underwent PPH taken from a medical records database. There were no significant differences in terms of demographic data, type of anaesthesia, operative time, and blood loss. Length of hospital stay, time to first post-operative bowel movement, and complications were similar between the two groups. The median pain score after THD and PPH was 1.71 and 5.00, respectively, on a scale of 0-10 (10 = worst possible pain) (p = 0.000). There was a significant improvement in bleeding and prolapse scores after THD. THD patients had an earlier return to normal daily activities (3.13 vs. 6.78 days, p = 0.001) when compared with the PPH group. Upon follow-up, patients in both groups had similar satisfaction scores, and complication and recurrence rates.

CONCLUSIONS

Both THD and PPH appear to be safe procedures for haemorrhoidal disease, and they appear to have similar short-term outcomes. In particular, THD seems to be associated with a lower pain score than PPH, an earlier return to normal daily activities, and similar rates of complication and recurrence.

Predictors of early postoperative pain after stapled haemorrhoidopexy

AIM

Moderate to severe pain after stapled haemorrhoidopexy (SH) is not uncommon. This study was designed to identify the predictors of postoperative pain after SH in a single centre.

METHOD

Seventy-six patients with Grade II to IV haemorrhoids who underwent SH were selected from a prospectively compiled database. Preoperative data, including patient characteristics, manometry results and surgical data, were documented. Pain was evaluated during the first 24 h after the operation. Its intensity was classified into three grades according to the visual analogue scale (VAS) score: mild (VAS ≤ 3), moderate (VAS >3 to <5) and severe (VAS ≥ 5). Analgesics were not routinely given but were administered if the patient had moderate or severe pain. Both univariate and multivariate analyses were used to determine the predictors of postoperative pain.

RESULTS

Moderate and severe pain was noted in 43 (58.9%) patients. No patient was readmitted due to persistent anal pain during the month following discharge. Postoperative pain was significantly associated with gender (P = 0.017), age (P = 0.014), first initial sensory volume (P = 0.023) and constipation (P = 0.005) in univariate analysis. Multivariate analysis identified male gender as an independent predictor of postoperative moderate to severe pain (P = 0.037, OR = 3.1, 95% CI 1.07-9.09). The initial sensory volume and preoperative coexisting constipation were negative predictors of postoperative moderate to severe pain after SH (P = 0.037, OR = 0.320, 95% CI 0.110-0.934, and P = 0.036, OR = 0.255, 95% CI 0.071-0.913, respectively).

CONCLUSION

Male gender and the initial sensory volume are predictors of postoperative pain after SH. Anal manometry is recommended before the SH procedure. An active analgesia protocol should be considered for male patients with a low initial sensory volume after SH.

Circular vs. three-quadrant hemorrhoidectomy for end-stage hemorrhoids: short- and long-term outcomes of a prospective randomized trial

PURPOSE

Circumferential excisional hemorrhoidectomy (CEH) enables the surgeon to remove the encircling hemorrhoids completely. The purpose of this study is to compare the efficacy of CEH with that of Ferguson hemorrhoidectomy (FH) for end-stage hemorrhoids.

METHODS

Between February 1998 and December 2011, a prospective randomized trial was conducted with 688 patients who presented with end-stage hemorrhoids and underwent FH or CEH at our center.

RESULTS

The patient demographics, mean operative times, lengths of hospital stay, and cumulative rates of postoperative complications were similar in the study groups. Significant differences were revealed in the incidence of postoperative hemorrhage (9 vs. 0 patients in the FH and CEH groups, respectively; p = 0.002) and in the tendency to form anal stricture (15 vs. 32 patients in the FH and CEH groups, respectively; p = 0.02). However, all cases of anal strictures were easily managed by digital dilatations. At a mean follow-up of 7.4 (range, 1-14) years, accessible patients from the CEH group remained symptom free, whereas 126 of 308 patients in the FH group indicated that they had recurrent hemorrhoidal symptoms.

CONCLUSION

Without increasing postoperative complications, CEH demonstrates an advantage compared with FH, with regard to reducing the rate of recurrence to 0 through complete hemorrhoid removal.

Pneumoretroperitoneum after procedure for prolapsed hemorrhoid

Procedure for prolapsed hemorrhoid (PPH) is well recognized alternative to the traditional hemorrhoidectomy, and is associated with reduced pain and earlier return to normal activity. Over the past decade, there have been reports of severe life-threatening complications after a PPH, although the incidence is very low. Rectal perforation due to staple-line dehiscence is one of the serious complications that can cause severe pelvic sepsis or a pneumoretroperitoneum. Here, the first Korean case of a pneumoretroperitoneum due to staple-line dehiscence is described.

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.