Partial Stapled Hemorrhoidopexy Versus Circumferential Stapled Hemorrhoidopexy for Grade III to IV Prolapsing Hemorrhoids: A Randomized, Noninferiority Trial

Modified stapled hemorrhoidopexy for lower postoperative stenosis: A five-year experience

BACKGROUND

Stapled hemorrhoidopexy (SH) is currently a widely accepted method for treating the prolapse of internal hemorrhoids. Postoperative anal stenosis is a critical complication of SH. A remedy for this involves the removal of the circumferential staples of the anastomosis, followed by the creation of a hand-sewn anastomosis. Numerous studies have reported modified SH procedures to improve outcomes. We hypothesized that our modified SH technique may help reduce complications of anal stenosis after SH.

AIM

To compare outcomes of staple removal at the 3- and 9-o'clock positions during modified SH in patients with mixed hemorrhoids.

METHODS

This was a single-center, retrospective, observational study. Patients with grade III or IV hemorrhoids who underwent standard or modified SH at our colorectal center between January 1, 2015, and January 1, 2020, were included. The operation time, blood loss, length of hospital stay, and incidence of minor or major complications were recorded.

RESULTS

Patients with grade III or IV hemorrhoids who underwent standard or modified SH at our colorectal center between January 1, 2015 and January 1, 2020, were included. Operation time, blood loss, length of hospital stay, and incidence of minor or major complications were recorded. We investigated 187 patients (mean age, 50.9 years) who had undergone our modified SH and 313 patients (mean age, 53.0 years) who had undergone standard SH. In the modified SH group, 54% of patients had previously undergone surgical intervention for hemorrhoids, compared with the 40.3% of patients in the standard SH group. The modified SH group included five (2.7%) patients with anal stenosis, while 21 (6.7%) patients in the standard SH group had complications of anal stenosis. There was a significant relationship between the rate of postoperative anal stenosis and the modified SH: 0.251 (0.085-0.741) and 0.211 (0.069-0.641) in multiple regression analysis. The modified SH technique is a safe surgical method for advanced grade hemorrhoids and might result in a lower rate of postoperative anal stenosis than standard SH.

CONCLUSION

The modified SH technique is a safe surgical method for advanced grade hemorrhoids and might result in a lower rate of postoperative anal stenosis than standard SH.

Modified whitehead hemorrhoidectomy versus partial hemorrhoidectomy for fourth-degree circular mixed hemorrhoids: A retrospective analysis

Background

Grade IV circular hemorrhoids are difficult to treat. We aim to describe the modified whitehead hemorrhoidectomy procedure and to assess the effectiveness and safety of this procedure for grade IV circular hemorrhoid patients.

Methods

Patients with grade Ⅳ circular hemorrhoids who underwent modified Whitehead hemorrhoidectomy and partial hemorrhoidectomy for fourth-degree circular mixed hemorrhoids were retrospectively reviewed. Clinical data were extracted from the database at our institution, and long-term postoperative complications were assessed through repeated outpatient examinations and telephonic communication.

Results

A total of 205 patients were included in this study. The mean operative time was 59.2 ± 13.8 min. The average hospital stay was 4.6 ± 1.0 days. For postoperative complications, 66 (32.2%) patients had urinary retention, 10 (4.9%) patients had a sense of incomplete rectal emptying, 5 (2.4%) patients had anal incontinence, and 6 (2.9%) patients had wound infection. For long-term postoperative complications, 3 (1.5%) patients experienced mild to moderate anal stricture, 2 (1%) patients experienced mucosal ectropion, they all had smooth recoveries, and none of them needed secondary surgery. None of these patients had a hemorrhoid recurrence. A total of 205 patients who received modified Whitehead hemorrhoidectomy and 161 who received partial hemorrhoidectomy were included. There were no residual hemorrhoids in patients who received modified Whitehead hemorrhoidectomy, and none had hemorrhoid recurrence. Fifty-eight patients who received partial hemorrhoidectomy had hemorrhoidal residues, and 19 patients experienced hemorrhoid recurrence. After modified Whitehead hemorrhoidectomy, 3 patients developed anal stenosis, and 2 had mucosal ectropion. Four patients developed anal stricture after partial hemorrhoidectomy, and none had mucosal ectropion. They all had smooth recoveries, and none of them needed a secondary surgery. For the mean duration of surgery, postoperative bleeding, postoperative pain, wound infection, sense of incomplete rectal emptying, anal incontinence, and urinary retention, no statistically significant differences were found between the two groups.

Conclusions

Compared with partial hemorrhoidectomy, modified whitehead hemorrhoidectomy is an effective and safe surgical procedure and does not significantly increase the risk of anal stenosis and mucosal ectropion for grade IV circular hemorrhoid patients. Prospective randomized controlled trials are needed to verify our results.

The comparison of an accessible C-shaped partial stapled hemorrhoidopexy (C-PSH) versus circular stapled hemorrhoidopexy (CSH) in patients with grade IV hemorrhoids: a retrospective cohort study

OBJECTIVES

The objectives of this study were to present an accessible C-shaped partial stapled hemorrhoidopexy (C-PSH) in the treatment of grade IV hemorrhoids and to assess long-term outcomes of this technique compared with circular stapled hemorrhoidopexy (CSH).

METHODS

Conventional CSH kits combined with an intestinal spatula were used for performing C-PSH. A total of 256 patients with grade IV hemorrhoids referred to Hangzhou Third People's Hospital between January 2016 and June 2017 were obtained: 122 (47.7%) with C-PSH, and 134 (52.3%) with CSH. After propensity score matching, 222 patients (111 in C-PSH group and 111 in CSH group) were ultimately analyzed. The primary outcome was the five-year recurrence rate of hemorrhoids. Secondary outcomes included intraoperative outcomes, postoperative outcomes and complications.

RESULTS

The operative time in the C-PSH group was slightly longer than that in the CSH group (p < 0.01). The vertical length of rectal mucosa specimen in the C-PSH group was shorter than that in the CSH group (p < 0.01). Compared with the CSH group, fecal urgency incidence and numeric rating scale (NRS) score at first defecation were lower in the C-PSH group (p < 0.05). Major complication rate in the CSH group was higher than that in the C-PSH group (p = 0.03). Five-year recurrence rate between the C-PSH group and CSH group was comparable (p > 0.05). Multivariate Cox regression analysis revealed that constipation was an independent prognostic factor for hemorrhoidal recurrence.

CONCLUSIONS

The accessible C-PSH seems to be a safe and effective technique in managing grade IV hemorrhoids. It has advantages in alleviating postoperative pain at first defecation, fecal urgency and major complications compared with CSH. It could be an alternative technique in the treatment of grade IV hemorrhoids.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The efficiency and safety of modified tissue-selecting therapy stapler combined with complete anal canal epithelial preservation operation in circumferential mixed hemorrhoids: a randomized controlled trial

PURPOSE

This study aimed to explore the efficiency and safety of modified tissue-selecting therapy stapler combined with complete anal canal epithelial preservation operation (M-TST-CACP) in the treatment of circumferential mixed hemorrhoids.

METHODS

This was a single-center, statistical analyst-blinded, randomized controlled trial (RCT). A total of 306 patients were finally included for analysis. The efficiency (efficacy, recurrence, anal smoothness, quality of life, and wound healing time) and safety (anal incontinence, pain level, anal stenosis, urinary retention, perianal edema, and postoperative bleeding) were evaluated. The statistical difference in continuous data between M-TST-CACP group and procedure for prolapse and hemorrhoids (PPH) group was compared using t-test or Mann-Whitney U test. The statistical difference in counting data between the two groups were compared using Pearson χ2 test. Difference within each group in different time points was evaluated using repeated-measures analysis of variance.

RESULTS

M-TST-CACP group showed a higher cure rate (6 months: 74.51% vs. 64.71%, P = 0.044), lower recurrence (6 months: 0% vs. 4.58%, P = 0.015; 12 months: 0.65% vs. 5.88%, P = 0.010), lower anal incontinence score (1 month: 1.29 ± 1.17 vs. 1.93 ± 1.33; 3 months: 1.07 ± 0.87 vs. 1.59 ± 1.01; 6 months: 0.58 ± 0.61 vs. 1.00 ± 0.90; all P < 0.001), and lower rate of anal stenosis (1 month: 0% vs. 7.84%; 3 months: 0% vs. 9.80%; both P < 0.001) than the PPH group.

CONCLUSIONS

M-TST-CACP had better efficiency and safety than the PPH, which could be a reasonable adoption for the surgeons to treat circumferential mixed hemorrhoids.

PROSPECT guideline for haemorrhoid surgery: A systematic review and procedure-specific postoperative pain management recommendations

BACKGROUND

Haemorrhoidectomy is associated with moderate-to-severe postoperative pain.

OBJECTIVE

The aim of this systematic review was to assess the available literature and update previous PROSPECT (procedure specific postoperative pain management) recommendations for optimal pain management after haemorrhoidectomy.

DESIGN AND ELIGIBILITY CRITERIA

A systematic review utilising PROSPECT methodology was undertaken.

DATA SOURCES

Randomised controlled trials published in the English language from January 1, 2016 to February 2, 2022 assessing postoperative pain using analgesic, anaesthetic, and surgical interventions were identified from MEDLINE, EMBASE and Cochrane Database.

RESULTS

Of the 371 randomized controlled trials (RCTs) identified, 84 RCTs and 19 systematic reviews, meta-analyses met our inclusion criteria (103 publications). Interventions that improved postoperative pain relief included: paracetamol and nonsteroidal anti-inflammatory drugs or cyclo-oxygenase-2 selective inhibitors, systemic steroids, pudendal nerve block, topical metronidazole, topical diltiazem, topical sucralfate or topical glyceryl trinitrate, and intramuscular injection of botulinum toxin.

DISCUSSION

This review has updated the previous recommendations written by our group. Important changes are abandoning oral metronidazole and recommending topical metronidazole, topical diltiazem, topical sucralfate, topical glyceryl trinitrate. Botulinum toxin can also be administered. Contemporary publications confirm the analgesic effect of bilateral pudendal nerve block but invalidate recommendations on perianal infiltration. The choice of the surgery is mostly left to the discretion of the surgeons based on their experience, expertise, type of haemorrhoids, and risk of relapse. That said, excisional surgery is more painful than other procedures.

Electroacupuncture at Baliao point alleviates post-operative pain and anal distension after procedure for prolapse and hemorrhoids (stapled hemorrhoidopexy): a prospective randomized clinical trial

PURPOSE

The purpose of this study was to explore the effect of electroacupuncture (EA) at Baliao point on short-term complications, such as anal pain and swelling, after procedure for prolapse and hemorrhoids (PPH) in patients with mixed hemorrhoids.

METHODS

A total of 124 eligible patients undergoing PPH surgery were included in this study and randomly divided into a control group (n = 67) and an EA group (n = 57), with patients in the control group receiving only PPH surgery and patients in the EA group receiving PPH surgery and EA at Baliao point.

RESULTS

The visual analogue scale (VAS) scores of EA group at 8, 24, 48, and 72 h after operation were significantly lower than those of control group. The anal distension scores at 8, 48, and 72 h after operation were also significantly lower than those of control group. The number of postoperative analgesic drug administration per patient was also significantly lower in the EA group. The incidence of urinary retention and tenesmus in EA group was significantly lower than that in control group within the first day after surgery.

CONCLUSION

EA treatment at the Baliao point can alleviate short-term anal pain and anal swelling after the procedure for prolapse and hemorrhoids, reduce the incidence of urinary retention, and decrease the use of postoperative analgesic drugs.

TRIAL REGISTRATION

This study was approved and registered by the Chinese Clinical Trial Center, Registration number: ChiCTR2100043519, Registration time: February 21, 2021 ( https://www.chictr.org.cn/ ).

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.

Outcomes of Modified Tissue Selection Therapy Stapler in the Treatment of Prolapsing Hemorrhoids

Objective

Tissue selection therapy staplers (TSTs) are widely used to treat prolapsing hemorrhoids; however, some disadvantages exist. We describe a modified technique for the treatment of prolapsing hemorrhoids, with the aim of minimizing the risk of anal stenosis and anal incontinence and reducing the impact of postoperative complications from the stapling technique. We applied a modified TST procedure, and the preliminary data were used to test the efficacy and safety of this new technique.

Methods

We conducted a retrospective study of patients who underwent modified TST for prolapsing hemorrhoids at our department between January 2018 and January 2020. All patients received a modified TST. Most prolapsing hemorrhoids were not segmentally resected and were instead selectively removed. The demographics, preoperative characteristics, postoperative complications, therapeutic effects, and patient satisfaction were collected and analyzed.

Results

A total of 106 patients were included in the study; 53 were men and 53 women (mean age, 49.24 years). The mean operative time was 55.01 min, and the mean hospital stay was 7.82 days. After surgery, three patients experienced bleeding (2.83%), 2 patients experienced anal discharge (1.89%), 2 patients experienced tenesmus (1.89%), and 5 patients experienced anal tags (4.72%). Anal incontinence, persistent post stapler pain, rectovaginal fistula and anal stenosis did not occur. Two patients developed recurrent symptomatic hemorrhoids (1.89%). The total effective rate of the surgery and the total satisfaction rate of the patients was 97.17%.

Conclusions

The modified tissue selection therapy stapler technique was a satisfactory and economical treatment for prolapsing hemorrhoids at a follow-up period of 1 year. The modified TST was associated with reduced anal stenosis and anal incontinence, less persistent post stapler pain and a minimal risk of rectovaginal fistula.

A NEW MIXED SURGICAL TREATMENT FOR GRADES III AND IV HEMORRHOIDS: MODIFIED SELECTIVE HEMORRHOIDECTOMY COMBINED WITH COMPLETE ANAL EPITHELIAL RETENTION

BACKGROUND

Varicose veins appear above and below the dentate line in mixed hemorrhoids, which seriously affects anal function and quality of life.

AIM

To propose an improvement in tissue-selecting therapy repair of anal pad combined with complete anal canal epithelial retention comparing with Milligan-Morgan surgery.

METHODS

A prospective randomized controlled study was designed enrolling 200 patients with grade III and IV hemorrhoids. They were divided into control and observation groups. The control received Milligan-Morgan surgery, and the observation the modified tissue-selecting therapy stapler combined with complete anal canal preservation surgery. All patients were followed for six months to evaluate the treatment differences.

RESULTS

In final, control group included 82 and observation 87. The average operation time of the control group was significantly lower than that of the observation, while the bleeding volume was significantly lower in control group. The control group VAS score was 3 (1, 4), and observation 4 (2, 5). There was no significant difference in the incidence of urinary retention, bleeding and wound margin edema after surgery at one month postoperatively. Digital incidence of anal stenosis in the observation group was significantly lower than in control; the same occurred with residual anal margins. The postoperative anal canal diameter was significantly larger than the control group. Wexner anal incontinence score showed that no anal incontinence occurred in both groups, and the control group scored was significantly higher than observation. In final six months follow-up, the observation group did not experience any relapse and four cases were found among controls. The treatment satisfaction of the observation group was better.

CONCLUSIONS

In grades III and IV hemorrhoids, modified tissue-selecting therapy combined with complete anal canal preservation had better prognosis and treatment satisfaction than Milligan-Morgan procedure, and it is a new surgical method for patients with advanced mixed hemorrhoids.

An update on surgical treatment of hemorrhoidal disease: a systematic review and meta-analysis

BACKGROUND

Pathologic hemorrhoids are common among adults age 45-65. Hemorrhoids are characterized as internal or external, and grades 1-4 based on severity. The type and grade dictate treatment, with surgical treatment reserved for grades 3/4. The aim of this study is to compare clinical outcomes of various surgical treatments.

METHODS

A systematic review was conducted to identify randomized clinical trials that compare surgical treatments for grade 3/4 hemorrhoids. A Bayesian network meta-analysis was done using NetMetaXL and WinBUGS.

RESULTS

A total of 26 studies with 3137 participants and 14 surgical treatments for grade 3/4 hemorrhoids were included. Pain was less in patients with techniques such as laser (OR 0.34, CI 0.01-6.51), infrared photocoagulation (OR 0.38, CI 0.02-5.61), and stapling (OR 0.48, CI 0.19-1.25), compared to open and closed hemorrhoidectomies. There was less recurrence with Starion (OR 0.01, CI 0.00-0.46) and harmonic scalpel (OR 0.00, CI 0.00-0.49), compared to infrared photocoagulation and transanal hemorrhoidal dearterialization. Fewer postoperative clinical complications were seen with infrared photocoagulation (OR 0.04, CI 0.00-2.54) and LigaSure (OR 0.16, CI 0.03-0.79), compared to suture ligation and open hemorrhoidectomy. With Doppler-guided (OR 0.26, CI 0.05-1.51) and stapled (OR 0.36, CI 0.15-0.84) techniques, patients return to work earlier when compared to open hemorrhoidectomy and laser.

CONCLUSION

There are multiple favorable techniques without a clear "gold standard" based on current literature. Open discussion should be had between patients and physicians to guide individualized care.

Long-Term Outcomes of Sectorial Longitudinal Augmented Prolapsectomy for Asymmetric Muco-hemorrhoidal Prolapse: An Observational Study of 433 Consecutive Patients

PURPOSE

Hemorrhoidal disease (HD) is a widespread condition severely influencing patients' quality of life. Recently, the large diffusion of stapled hemorrhoidopexy has revealed a new unexpected pathological entity: the asymmetric mucosal prolapse. We aimed to assess the outcomes of the sectorial longitudinal augmented prolapsectomy (SLAP), a technique dedicated to asymmetric prolapse, in terms of HD symptoms, prolapse recurrence, and rectal stenosis.

METHODS

Patients affected by III-IV-degree symptomatic HD with asymmetric mucosal prolapse undergone SLAP of 1 or 2 hemorrhoidal columns (SLAP1 or SLAP2) were retrospectively assessed. The severity of hemorrhoid symptoms and fecal continence status were evaluated before and after surgery. Mean outcome was evaluation of medium-long-term outcomes as the occurrence of recurrence and anal or rectal stenosis. Secondary outcome was the evaluation of postoperative bleeding, reoperation rate, length of hospitalization, fecal urgency, and time to return to work.

RESULTS

We enrolled 433 patients (277 SLAP1 and 156 SLAP2). Hemorrhoidal symptoms recurrence was reported in 9 patients undergone SLAP1 and 4 patients undergone SLAP2, while prolapse recurrence occurred, respectively, in 4 and 2 patients. No major intraoperative complications occurred. An emergency reintervention for postoperative bleeding occurred in 13 cases undergone SLAP1 and in 5 patients treated with SLAP2. Fecal incontinence occurred in 8 and 4 cases of patients treated with SLAP1 and SLAP2.

CONCLUSIONS

The combination of a simple hemorrhoidectomy to a mucosal rectal prolapsectomy should be part of every coloproctologist background. Promising and satisfying results can be achieved using SLAP for HD associated with asymmetric prolapse.

Perirectal Hematoma and Intra-Abdominal Bleeding after Stapled Hemorrhoidopexy and STARR-A Proposal for a Decision-Making Algorithm

Background and Objectives: The present study aims to assess the effectiveness and current evidence of the treatment of perirectal bleeding after stapled haemorrhoidopexy. Materials and methods: A systematic literature review was performed that combined the published and the obtained original data after a search of PubMed, Web of Science, and SCOPUS. Results: The present systematic review includes 16 articles with 37 patients. Twelve papers report perirectal and six report intra-abdominal bleeding. Stapled hemorrhoidopexy (SH) was performed in 57% of cases (3 PPH 01 and 15 PPH 03), stapled transanal rectal resection (STARR) in 13%, and for 30% information was not available. The median age was 49 years (±11.43). The sign and symptoms of perirectal bleeding were abdominal pain (43%), pelvic discomfort without rectal bleeding (36%), urinary retention (14%), and external rectal bleeding (21%). The median time to bleeding was 1 day (±1.53 postoperative days), with median hemoglobin at diagnosis 8.8 ± 1.04 g/dL. Unstable hemodynamic was reported in 19%. Computed tomography scan (CT) was the first examination in 77%. Only two cases underwent the abdominal US, but subsequently, a CT scan was also conducted. Non-operative management was performed in 38% (n = 14) with selective arteriography and percutaneous angioembolization in two cases. A surgical treatment was performed in 23 cases - transabdominal surgery (3 colostomies, 1 Hartmann' procedure, 1 low anterior resection of the rectum, 1 bilateral ligation of internal iliac artery and 1 ligation of vessels located at the rectal wall), transanal surgery (n = 13), a perineal incision in one, and CT-guided paracoccygeal drainage in one. Conclusions: Because of the rarity and lack of experience, no uniform tactic for the treatment of perirectal hematomas exists in the literature. We propose an algorithm similar to the approach in pelvic trauma, based on two main pillars -hemodynamic stability and the finding of contrast CT.

Evacuatory Dysfunction after Stapled Hemorrhoidopexy: A Case Report of Rectal Pocket Syndrome

A 60 year-old male was referred to the authors' hospital with a persistent urge to defecate. The patient had undergone stapled hemorrhoidopexy (SH) for the treatment of prolapsed hemorrhoids approximately 10 years earlier. He started to have difficulty with defecation and a false sense of urgency shortly after the surgery. Computed tomography showed a diverticulum-like fistula along the circumference of the rectum. Colonoscopy revealed communication between the diverticular cavity and the rectal lumen. The cavity contained a thumbnail-sized fecalith. When the fecalith was removed, the patient's urge to defecate dissipated. The patient was diagnosed with rectal pocket syndrome secondary to SH. The lower rectum was transected, and the remaining rectum and the anal canal were anastomosed by manual suture. Temporary ileostomy with double orifices was performed. The ileostomy was closed 3 months later. The patient experienced no subsequent difficulty with defecation or urgency.