Scientific Articles on Hemorrhoidectomy - 2002

Stapled haemorrhoidectomy compared with Milligan-Morgan excision for the treatment of prolapsing haemorrhoids: a prospective study.

Goulimaris I, Kanellos I, Christoforidis E, Mantzoros I, Odisseos Ch, Betsis D.

4th Surgical Department of Aristotle University of Thessaloniki, Greece. ygouli@in.gr

Eur J Surg. 2002; 168(11): 621-5.

OBJECTIVE: To compare stapled haemorrhoidectomy with Milligan-Morgan haemorrhoidectomy. DESIGN: Prospective open study. SETTING: Teaching hospital, Greece. PATIENTS: 85 patients with prolapsing haemorrhoids were invited to choose between stapled and Milligan-Morgan haemorrhoidectomy. 48 chose the former and 37 the latter. INTERVENTIONS: Operation. Postoperatively, the patients were given analgesics on demand, and were discharged as soon as their condition and particularly their pain had improved. MAIN OUTCOME MEASURES: Patients' symptoms and their opinion about the procedures, which were recorded during their follow-up which lasted for 6 months. RESULTS: Stapling resulted in a significantly shorter operating time, and less postoperative pain and other symptoms, than Milligan-Morgan excision (p < 0.001). Postoperative complications, and mean time in hospital did not differ significantly between the two groups. During the follow-up period there was no significant difference in the incidence of recurrences between the two groups. Six months after the operation, significantly more patients in the stapled group had residual skin tags-external haemorrhoids than in the Milligan-Morgan group, and all these patients had fourth degree haemorrhoids. CONCLUSIONS: Stapled haemorrhoidectomy is a promising method of treatment for prolapsing third degree haemorrhoids. Its effectiveness is questionable for fourth degree ones. Initially, the results are as good as after Milligan-Morgan haemorrhoidectomy, especially for third degree haemorrhoids. However, more patients and longer follow-up periods are required for its long-term efficacy to be confirmed.

Haemorrhoidectomy in outpatient practice.

Labas P, Ohradka B, Cambal M, Olejnik J, Fillo J.

1st Department of Surgery, University Hospital Bratislava, Bratislava, Slovak Republic. peterlabas@hotmail.com

Eur J Surg. 2002; 168(11): 619-20.

OBJECTIVE: To evaluate our results of haemorrhoidectomy done as an outpatient procedure. DESIGN: Retrospective study. SETTING: University hospital Bratislava, Slovak Republic. SUBJECT: 256 patients who required haemorrhoidectomy in 1996-2001. INTERVENTIONS: Milligan-Morgan haemorrhoidectomy under local (0.5% lignocaine with adrenaline 1:200,000, 100 ml) or epidural (0.5 bupivacaine, marcain, 20 ml; or 1% lignocaine, 20 ml). MAIN OUTCOME MEASURES: Mortality, morbidity, need for admission to hospital, and acceptability to patients. RESULTS: No patient died. All patients were observed in the recovery room for 0.5-8 hours (mean 5 hours). 23 of the 256 patients (9%) developed minor complications including bleeding (n = 6), pain (n = 15), anal discharge (n = 1), and retention of urine (n = 1). 5 patients (2%) were admitted for pain or retention of urine. During the first 3 days after operation 29 patients required increased analgesia for discomfort. 223 patients (87%) were satisfied with outpatient treatment, while the remaining would have preferred to be admitted to hospital. CONCLUSION: Day case haemorrhoidectomy is a safe and effective way of reducing costs without increasing morbidity, mortality, and is acceptable to most patients.

[Surgical treatment of anal stenosis following hemorrhoid surgery. Results of 150 combined mucosal advancement and internal sphincterotomy]

Carditello A, Milone A, Stilo F, Mollo F, Basile M.

Dipartimento di Discipline Chirurgiche Generali e Speciali Policlinico Universitario di Messina.

Chir Ital. 2002 Nov-Dec; 54(6): 841-4. [Article in Italian]

The aim of the study was to evaluate the efficacy of anoplasty by mucosal advancement combined with internal sphincterotomy for the treatment of iatrogenic anal stenosis. From January 1990 to December 2000, 149 patients with post-haemorrhoidectomy anal strictures underwent internal sphincterotomy and mucosal advancement flap anoplasty. Seventy-one percent of patients were operated on under local anaesthesia by perineal block according to Marti. In 90 percent of the patients, postoperative pain was mild. No significant complications were seen. The mean hospital stay was two days. Ninety-seven percent of patients were well satisfied with the surgical result one year after operation. Current surgical options for the treatment of post-haemorrhoidectomy anal stricture are reported and the advantages of mucosal advancement flap anoplasty outlined.

[Advantages of surgical treatment of hemorrhoids with mechanical sutures]

Finco C, Sarzo G, Parise P, Savastano S, Merigliano S.

Clinica Chirurgica Generale IV U.O. Funzionale di Chirurgia Colo-proctologica Dipartimento di Scienze Mediche e Chirurgiche Universita degli Studi di Padova, ASL n. 16, Via Facciolati 71, 35127 Padova.

Chir Ital. 2002 Nov-Dec; 54(6): 835-9. [Article in Italian]

The use of circular staplers for the treatment of haemorrhoids is a new technique that

makes for better correction of the physiopathology of the condition, affords greater patient comfort and reduces health-care expenditure. This technique, which was invented by A. Longo in 1993, pulls up the haemorrhoidal cushions into their anatomical position, reduces or avoids postoperative pain, sparing the sensitive fibres of the anal canal, avoids anal canal stenosis and is not complicated by faecal incontinence. The authors present their experience in 41 patients affected by symptomatic haemorrhoidal prolapse and treated with a mucosal rectal prolapsectomy using a circular stapler. Each patient was followed up for 6 months to assess the incidence of complications and the degree of patient satisfaction. The results were compared with those reported in the literature, obtained using the Milligan-Morgan procedure. The Longo technique, which can be performed in the one-day surgery setting, allows very good relief of postoperative pain, rapid functional recovery and an early return to work, with a saving in health-care expenditure as compared with conventional treatment.

Long-term results of haemorrhoidectomy.

Johannsson HO, Graf W, Pahlman L.

Department of Surgery, Falu District Hospital, Falun, Sweden. helgi-orn.johannsson@ltdalarna.se

Eur J Surg. 2002; 168(8-9): 485-9.

OBJECTIVE: To assess the long-term functional results of Milligan-Morgan haemorrhoidectomy. DESIGN: Retrospective multicentre study. SETTING: One university hospital, one county hospital, and two community hospitals, Sweden. SUBJECTS: 507 of 556 patients who were operated on for haemorrhoids by the Milligan-Morgan technique between January 1987 and December 1995. INTERVENTION: A questionnaire was sent to all 507 patients, the questions in which focused on functional results and satisfaction. MAIN OUTCOME MEASURES: Patients' satisfaction and symptoms of anal incontinence after haemorrhoidectomy. RESULTS: 418 of the 507 responded (82%). Altogether 279 patients (67%) reported a successful result, while 139 patients (33%) reported impaired anal continence. 40 of the 139 patients (29%) claimed that the incontinence was a direct result of the haemorrhoidectomy. Female sex (p = 0.005) and an operation for hygienic problems (p = 0.02) were associated with a higher risk of incontinence. CONCLUSION: Impaired anal continence is common after Milligan-Morgan haemorrhoidectomy and a large proportion of affected patients relate their problems to the operation.

Haemorrhoidectomy: randomised controlled clinical trial of Ligasure compared with Milligan-Morgan operation.

Thorbeck CV, Montes MF.

Surgery Department, Hospital Clinico Universitario Virgen de la Victoria, Malaga, Spain.

Eur J Surg. 2002; 168(8-9): 482-4.

OBJECTIVE: To evaluate the efficacy of the Ligasure system in the management of haemorrhoids. DESIGN: Unblinded randomised clinical trial. SETTING: Teaching hospital, Spain. PATIENTS: 112 patients with third and fourth degree haemorrhoids. INTERVENTIONS: For 56 patients we used Ligasure system and a variant of Milligan and Morgan's technique. For the other 56, we used the traditional technique. MAIN OUTCOME MEASURES: Postoperative pain. RESULTS: Operating times varied from 100 seconds for each haemorrhoidal cushion with Ligasure system to the 313 seconds by the traditional technique. The blood loss was not quantifiable in patients operated on with Ligasure. Pain was scored on a visual analogue scale. In the Ligasure group, the mean scores were 4.9 (immediate postoperative period) and 2.3 (24 hours later). In the other group, the scores were 7.8 and 6.9. These differences were significant. CONCLUSION: Haemorrhoidectomy using Ligasure as a technical variant of Milligan and Morgan's technique has important advantages.

Modified stapled haemorrhoidopexy for the treatment of massive circumferentially prolapsing piles.

Jayne DG, Seow-Choen F.

Department of Colorectal Surgery, Level 7, Block 6, Singapore General Hospital, Outram Road, Singapore 169608.

Tech Coloproctol. 2002 Dec; 6(3): 191-3.

Stapled haemorrhoidopexy is becoming the procedure of choice for the treatment of symptomatic prolapsing piles. However, it can be technically difficult if the piles are massively enlarged and prolapsing circumferentially through the anal canal. We describe a novel method that combines both diathermy and stapled excision, producing complete haemorrhoidal eradication with anorectal mucosal fixation above the dentate line.

Randomised trial comparing LigaSure haemorrhoidectomy with the diathermy dissection operation.

Milito G, Gargiani M, Cortese F.

Department of General Surgery, Tor Vergata University of Rome, Italy.

Tech Coloproctol. 2002 Dec; 6(3): 171-5.

The study was designed to compare LigaSure haemorrhoidectomy with open haemorrhoidectomy performed by means of diathermy excision. Fifty-sixty consecutive patients with third- and fourth-degree haemorrhoids were randomly allocated to undergo either LigaSure haemorrhoidectomy (29 patients) or diathermy haemorrhoidectomy (27 patients). All patients were evaluated for operative time, pain, post-operative analgesic requirements, time to first bowel movement, length of hospital stay, wound healing period, time to return to work, and occurrence of early postoperative complications (such as urinary dysfunction, bleeding, soiling, seepage, continence disorders) and late complications (such as stenosis). A statistically significant advantage was observed in the patients who received the LigaSure technique as far as concerns length of operative time (9.2 vs. 12.2 min, p<0.001), post-operative analgesic requirements (14.1 vs. 16.8 administrations, p<0.001), wound healing period (16.3 vs. 37.5 days, p< 0.0001), and time to return to work (8.3 vs. 18.3 days, p<0.01). No significant difference was seen in the postoperative pain score, complications rate, first bowel motion or hospital stay. No recurrence was observed at the 6-month follow-up. In conclusion, our experience shows that the LigaSure haemorrhoidectomy offers definite advantages over the classic diathermy technique. This procedure is easier, safer, and more rapid to perform and is followed by a faster wound healing time, a significantly shorter hospital stay, less postoperative pain and faster wound healing.

A systematic review of stapled hemorrhoidectomy.

Sutherland LM, Burchard AK, Matsuda K, Sweeney JL, Bokey EL, Childs PA, Roberts AK, Waxman BP, Maddern GJ.

ASERNIP-S, 51-54 Palmer Pl, North Adelaide, South Australia 5006, Australia.

Arch Surg. 2002 Dec; 137(12): 1395-406; discussion 1407.

HYPOTHESIS: Use of circular stapled hemorrhoidectomy will result in the same or improved safety and efficacy outcomes as those of the conventional methods for hemorrhoidectomy in patients with hemorrhoids. DATA SOURCES: Studies on stapled hemorrhoidectomy were identified using PREMEDLINE and MEDLINE (June 1966-June 2001), EMBASE (January 1980-June 2001), Current Contents (June 1993-June 2001), Ovid HEALTHSTAR (January 1975-June 2001), the National Institutes of Health Clinical Trials database (searched June 13, 2001), and The National Coordinating Centre for Health Technology Assessment database (searched June 14, 2001). The search terms were as follows: haemorrhoid* and (stapl* or convent*) or hemorrhoid* and (stapl* or convent*). The Cochrane Library (2001, issue 2) was searched using the search terms haemorrhoid* or hemorrhoid*. STUDY SELECTION: Articles detailing randomized controlled trials were included if they compared circular stapled with conventional hemorrhoidectomy and provided relevant safety and efficacy outcome information. DATA EXTRACTION: Data from all included studies were extracted using standardized data extraction tables that were developed a priori. In addition, the randomized controlled trials were examined with respect to the adequacy of allocation concealment, handling of those unavailable for follow-up, and any other aspect of the study design or execution that may have introduced bias. DATA SYNTHESIS: Seven randomized controlled trials met the inclusion criteria. A meta-analysis was conducted when the studies had comparable outcomes, inclusion criteria, and follow-up. There was reasonably clear evidence in favor of the stapled procedure for bleeding at 2 weeks (relative risk, 0.55; 95% confidence interval, 0.37-0.82) and length of hospital stay (weighted mean difference, -0.89 days; 95% confidence interval, -1.42 to -0.36). Other less robust results in favor of the stapled hemorrhoidectomy related to pain, bleeding, anal discharge, wound healing, tenderness to per rectal examination, incontinence scores, earlier return of bowel function, analgesic requirement, and resumption of normal activities. One trial showed that prolapse occurred at significantly higher rates in the stapled hemorrhoidectomy group. However, the outcomes were poorly reported and generally showed statistically significant heterogeneity. CONCLUSIONS: Stapled hemorrhoidectomy may be at least as safe as conventional hemorrhoidal surgical techniques. However, the efficacy of the stapled procedure compared with the conventional techniques could not be determined. More rigorous studies with longer follow-up periods and larger sample sizes need to be conducted.

Combined perineal and endorectal repair of rectocele by circular stapler: a novel surgical technique.

Altomare DF, Rinaldi M, Veglia A, Petrolino M, De Fazio M, Sallustio P.

Department of Emergency and Organ Transplantation, General Surgery and Liver Transplantation Units, University of Bari, Policlinico, piazza G. Cesare 11, 70124 Bari, Italy.

Dis Colon Rectum. 2002 Nov; 45(11): 1549-52.

PURPOSE: The aim of this study was to present a new technique for treatment of disabling rectocele when associated with internal mucosal prolapse or hemorrhoids using a 33-mm circular stapler. METHODS: Eight female patients complaining of obstructed defecation because of distention rectocele associated with internal mucosal prolapse or hemorrhoids and perineal descent entered the study. The rectovaginal septum was opened by diathermy up to the end of the rectal wall weakness. The perineal wound and the anus were held open by a self-retractor. Using a transparent anoscope (PPH 01 system), 2 mucosal pursestrings were prepared 5 and 8 to 9 cm distant from the dentate line. Posteriorly, only the submucosa was included in the pursestring; anteriorly, it included the rectal wall, which was kept separate from the vaginal wall. A transanal 33-mm circular stapler was then used to close the rectocele and treat the mucosal prolapse. Before closing the perineum a levatorplasty was fashioned. RESULTS: One patient had a vaginal tear during dissection of the septum, which healed spontaneously in one month. No other complications were recorded. Postoperative defecography showed correction of the rectocele and the posterior rectal prolapse in all patients. In two of them, a small lateral diverticulum could be seen, although this was asymptomatic. After a median follow-up of 12 months, all had significantly improved defecation (chronic constipation score dropped from 14.3 to 5, P < 0.04). CONCLUSION: Combined perineal and endorectal stapler repair of rectocele may be a useful new surgical tool for correcting distention rectocele associated with mucosal prolapse or hemorrhoids and perineal descent in selected patients. A longer follow-up on a larger number of patients is needed to confirm these preliminary results.

Internal sphincterotomy with hemorrhoidectomy does not relieve pain: a prospective, randomized study.

Khubchandani IT.

Milton S. Hershey Medical Center, College of Medicine, Pennsylvania State University, Hershey, PA, USA.

Dis Colon Rectum. 2002 Nov; 45(11): 1452-7.

PURPOSE: Pain after hemorrhoidectomy is universal. Several attempts have been made to reduce or alleviate the pain after excisional hemorrhoidectomy. The origin of pain is undetermined. Current theories propose that the pain is mediated through the internal sphincter. This prospective, randomized study was performed to assess the degree of discomfort in patients with and without a sphincterotomy when performing a closed hemorrhoidectomy. METHODS: Between December 1999 and September 2001, 42 patients (22 males), median age 52 (range, 30-80) years, who underwent excisional hemorrhoidectomy were randomly chosen to have an internal sphincterotomy in the base of the left lateral wound. RESULTS: Thirty-nine patients were available for the study. Parameters elicited in the study were pain, postoperative bleeding, urinary retention, impairment of continence by day and by night, and day the patient returned to work. There was no statistical difference in the postoperative pain in each of the two categories at four hours after surgery, after the first bowel movement, or four days after surgery. CONCLUSIONS: Results showed no difference in the perception of pain after hemorrhoidectomy in patients who had an internal sphincterotomy compared with those who did not. Both groups were equally likely to have difficulty with control of gas and soiling.

Objective comparison of stapled anopexy and open hemorrhoidectomy: a randomized, controlled trial.

Wilson MS, Pope V, Doran HE, Fearn SJ, Brough WA.

Department of Surgery, Christie Hospital, Wilmslow Road, Withington, Manchester M20 4BX, United Kingdom.

Dis Colon Rectum. 2002 Nov; 45(11): 1437-44.

PURPOSE: This trial compares stapled anopexy with open hemorrhoidectomy in patients with prolapsing (Grade 3) hemorrhoids. Particular attention was paid to changes in anorectal physiology, nature of tissue resected, quality-of-life assessments, and cost implications of the treatments studied. METHODS: An initial pilot study was followed by a randomized, controlled trial in a District General Hospital in the United Kingdom. All patients had Grade 3 hemorrhoids. Nineteen patients were studied in the pilot study, with 99 patients in the randomized, controlled trial. All patients in the pilot study and 59 in the randomized, controlled trial underwent stapled anopexy. Thirty patients in the randomized, controlled trial underwent open hemorrhoidectomy. Of the 59 patients in the stapled group, 32 were treated with the Ethicon PPH stapling device, and 27 received stapling with a reusable Autosuture stapling device. The following variables were measured: demographic details, quality of life (Medical Outcomes Study Short Form 36 and directed questions), anorectal manometry, and histology. RESULTS: There was no difference in the case mix within or between the groups. The stapled anopexy groups showed a significant reduction in operative time (P < 0.001) and blood loss (P < 0.001) compared with open hemorrhoidectomy. Open hemorrhoidectomy resulted in significantly greater usage of protective pads postoperatively (P < 0.001) and longer rehabilitation (P < 0.006). CONCLUSIONS: Stapled anopexy is an effective alternative treatment for prolapsing hemorrhoids that allows reduced operative time and shorter rehabilitation. It does not appear to affect continence or overall quality of life.

[Surgical treatment of hemorrhoids in day-surgery]

Benfatto G, Zanghi G, Altadonna V, Licari V, Tenaglia L, Scilletta S, Catania G.

Dipartimento di Chirurgia, Sezione di Chirurgia Generale ed Oncologica, Universita degli Studi di Catania.

G Chir. 2002 Jun-Jul; 23(6-7): 275-8. [Article in Italian]

The Authors report their own experience with day-surgery treatment of haemorrhoids and underline the advantages in terms of patients' compliance and reduction of the sanitary management in order to the cost that this way suggests. The serie here reported includes 72 patients treated, by two years, with day-surgery haemorrhoidectomy. Here are indicated criteria of selection of the patients, related to the state of the illness, association of other pathologies and social factors. All the patients, moreover, have been treated according to a scheme that generally includes: a careful preoperatory valuation, local anaesthesia, standardized surgical method (Milligan-Morgan intervention), dimission few hours after the operation, control of the patients at their own home. The results obtained, careful examinted through an objective valuation (complications, relapses, time or reability) and subjective one (index of satisfaction of the patients), can be considered extremely positive.

Two-quadrant semiclosed hemorrhoidectomy. A preliminary report.

Pescatori M.

Coloproctology Unit of Villa Flaminia Hospital, Via L. Bodio 58, I-00191 Rome, Italy. ucpclub@virgilio.it

Tech Coloproctol. 2002 Sep; 6(2): 105-8.

Bleeding and delayed healing may affect the postoperative course following hemorrhoidectomy and cause discomfort to the patient. The present report deals with a modification of the Milligan-Morgan operation: the upper part of the surgical wound is covered with rectal mucosa and the distal edge is stitched with a running suture, with the aim of decreasing both the risk of bleeding and the healing time. The operation has been performed in 12 consecutive patients with two quadrant internal and external piles. The median operative time was 32 minutes (range, 21-30). The mean postoperative pain after 12 hours, measured from 1 to 10 on a visual analogue scale, was 4.4 (SEM, 1.4). All patients but three had their wounds healed within 3 weeks and none of them had postoperative bleeding requiring treatment. Acute urinary retention occurred in one case. All patients were discharged after 48 hours. None had anal incontinence or short-term recurrence. In conclusion, two-quadrant semiclosed hemorrhoidectomy provided good results in terms of both bleeding rate and healing process with an acceptable operative time and postoperative pain.

Harmonic scalpel hemorrhoidectomy: preliminary results of a new alternative method.

Ramadan E, Vishne T, Dreznik Z.

Department of Surgery A, Rabin Medical Center, Campus Golda, Sacklar Medical School, Tel-Aviv University, 7 Keren Kayemet Street, Petach-Tikva, Israel.

Tech Coloproctol. 2002 Sep; 6(2): 89-92.

Surgical treatment is considered to be the best therapeutic modality for severe hemorrhoidal disease. Different surgical methods of hemorrhoidectomy aim to decrease pain, bleeding, stenosis and discharge. The aim of this study was to evaluate the efficacy of harmonic scalpel hemorrhoidectomy. During a period of seven months, 54 consecutive patients with third- and fourth-degree hemorrhoids were prospectively randomized for harmonic scalpel hemorrhoidectomy (HS) or Milligan-Morgan procedure (MM). These patients were examined at one, two, and six weeks after the operation. All patients had a lower gastrointestinal investigation prior to operation to exclude other colorectal pathologies. All patients had the same kind of preoperative preparation and analgesia during the postoperative course. Pain was assessed using a visual analog scale from 0 to 10. Patient satisfaction was defined as decrease or absence of symptoms and return to normal daily activities. HS groups included 29 patients, while the MM group had 25 patients. There as no difference between the groups in terms of age, gender, hemorrhoidal degree and indication for operation. The types of intra-operative anesthesia administered to the two groups were similar. Duration of surgery was significantly higher in the MM group ( p<0.0001). Postoperative hospitalization was longer in the MM group ( p<0.0001), and the pain degree was higher in MM group ( p<0.0001). No significant difference was noted in the overall amount of analgesics used in the two groups at week 1, although it was significantly higher in the MM group 2 and 3 weeks after the operation. Early complication occurred more frequently in the MM group but overall the difference was not statistically significant. In conclusion, harmonic scalpel hemorrhoidectomy is virtually a bloodless operation with minimal tissue damage. It is associated with significant less postoperative pain and a fast return to normal activity.

Complications after stapled hemorrhoidectomy: can they be prevented?

Ravo B, Amato A, Bianco V, Boccasanta P, Bottini C, Carriero A, Milito G, Dodi G, Mascagni D, Orsini S, Pietroletti R, Ripetti V, Tagariello GB.

Rome American Hospital, Via Emilio Longoni 69, I-00155 Rome, Italy. nadia.fabrini@rahonline.com

Tech Coloproctol. 2002 Sep; 6(2): 83-8.

Stapled hemorrhoidectomy (SH), a new approach to the treatment of hemorrhoids, removes a circumferential strip of mucosa about four centimeters above the dentate line. A review of 1,107 patients treated with SH from twelve Italian coloproctological centers has revealed a 15% (164/1,107) complication rate. Immediate complications (first week) were: severe pain in 5.0% of all patients, bleeding (4.2%), thrombosis (2.3%), urinary retention (1.5%), anastomotic dehiscence (0.5%), fissure (0.2%), perineal intramural hematoma (0.1%), and submucosal abscess (0.1%). Bleeding was treated surgically in 24%, with Foley insertion 15%; and by epinephrine infiltration in 2%; 53% of patients with bleeding received no treatment and 6% needed transfusion. One patient with anastomotic dehiscence needed pelvic drainage and colostomy formation. The most common complication after 1 week was recurrence of hemorrhoids in 2.3% of patients, severe pain (1.7%), stenosis (0.8%), fissure (0.6%), bleeding (0.5%), skin tag (0.5%), thrombosis (0.4%), papillary hypertrophy (0.3%) fecal urency (0.2%), staples problems (0.2%), gas flatus and fecal incontinence (0.2%), intramural abscess, partial dehiscence, mucosal septum and intussusception (each <0.1%). Recurrent hemorrhoids were treated by ligation in 40% and by Milligan-Morgan procedure in 32%. All hemorrhoidal thromboses were excised. Anal stenoses were treated by dilatation in 55% and by anoplasty in 45%. Fissure was treated by dilatation in 57%. Most complications (65%) occurred after the surgeon had more than 25 case experiences of stapled hemorrhoidectomy. The most common complication in the first 25 cases of the surgeon's experience was bleeding (48%). Even though SH appears to be promising, we feel that a multicenter randomized study with a long-term follow-up comparing SH and banding is necessary before recommending the procedure. Most complications can be avoided by respecting the rectal wall anatomy in the execution of the procedure.

Stapled rectal mucosectomy vs. closed hemorrhoidectomy: a randomized, clinical trial.

Correa-Rovelo JM, Tellez O, Obregon L, Miranda-Gomez A, Moran S.

Colon and Rectum Clinic, Medica Sur Hospital, Mexico City, Mexico.

Dis Colon Rectum. 2002 Oct; 45(10): 1367-74; discussion 1374-5.

INTRODUCTION: We compared the safety and clinical outcome between stapled rectal mucosectomy and closed hemorrhoidectomy for the surgical treatment of noncomplicated hemorrhoidal disease. METHODS: Eighty-four patients with Grade III and IV hemorrhoidal disease were randomly assigned to two groups: 1) stapled rectal mucosectomy group (n = 42) and 2) closed hemorrhoidectomy group (n = 42). Postoperative pain, analgesic use, symptoms, disability, early and late complications, and patient satisfaction were evaluated, among others. Follow-up was six months. RESULTS: Eighty-four patients, averaging 45 +/- 9 years of age, underwent surgery. Two were lost to follow-up. Length of surgery and disability, postoperative pain, and use of analgesics were significantly less for patients in the stapled rectal mucosectomy group. In the closed hemorrhoidectomy group early complications were more frequent but not statistically significant, and there were no statistically significant differences regarding the frequency of late complications. No serious complications were reported in either group. Closed hemorrhoidectomy proved to be superior for bleeding control (95.1 percent closed hemorrhoidectomy 80.5 percent stapled rectal mucosectomy; P= 0.04). Patient satisfaction was similar in the two groups, but stapled rectal mucosectomy patients were more willing to undergo the same procedure (P = 0.02). CONCLUSION: Both stapled rectal mucosectomy and closed hemorrhoidectomy are safe procedures. Closed hemorrhoidectomy was superior for bleeding control in Grade III and IV hemorrhoidal disease, but more painful and disabling than stapled rectal mucosectomy.

Randomized clinical trial of stapled haemorrhoidopexy versus conventional diathermy haemorrhoidectomy.

Ortiz H, Marzo J, Armendariz P.

Unit of Coloproctology, Department of Surgery, Hospital Virgen del Camino, Irunlarrea 4, E-31008 Pamplona, Navarra, Spain. HHORTIZ@teleline.es

Br J Surg. 2002 Nov; 89(11): 1376-81.

BACKGROUND: The aim of this study was to compare the results of stapled haemorrhoidopexy (commonly called stapled haemorrhoidectomy) with those of conventional diathermy haemorrhoidectomy. METHODS: Fifty-five patients with symptomatic third- and fourth-degree haemorrhoids were randomized to either stapled haemorrhoidopexy (n = 27) or conventional diathermy haemorrhoid ectomy (n = 28). Operating time, postoperative pain, time to return to work, postoperative complications and effectiveness of haemorrhoidal symptom control were recorded. The mean follow-up was 15.9 months in the stapled haemorrhoidopexy group and 15.2 months in the conventional haemorrhoidectomy group. RESULTS: Mean pain intensity was significantly less in the stapled group (P = 0.001). There were no significant differences in the total number of complications, the length of absence from work or control of symptoms. Seven patients in the stapled group re-presented with prolapse compared with none in the conventional haemorrhoidectomy group (P = 0.004). This difference was also observed in the subset of patients with fourth-degree haemorrhoids (P = 0.003). CONCLUSION: The stapled operation was significantly less painful than conventional haemorrhoidectomy. However, the rate of recurrent prolapse was higher after stapled haemorrhoidopexy than after conventional diathermy haemorrhoidectomy.

[Stapled anopexy for prolapsed hemorrhoids--a new operation]

Raahave D.

Organkirurgisk afdeling, Tarm-Laboratoriet, Helsingor Sygehus, DK-3000 Helsingor. dera@fa.dk

Ugeskr Laeger. 2002 Aug 12; 164(33): 3862-5. [Article in Danish]

INTRODUCTION: Haemorrhoidectomy is associated with pain and open wounds. A new closed technique uses an intraluminal stapler to replace the prolapsed haemorrhoidal tissue to a normal anatomical position (anopexy) and to interrupt the vessels. We report our results, including the learning curve. MATERIAL AND METHODS: Forty patients with grade 4 haemorrhoids underwent operation, 26 women, median age 47 years (33-86), and 14 men, median age 53 years (34-75). Outcome parameters were hospital stay, pain score, surgical anatomy score before and after the operation, and complications, symptom-control and patient satisfaction. RESULTS: Eleven patients left hospital on the day of operation, 19 the day after. The median pain score was 3 (2-10) for the first four days and 1 on day 7 (0-4). The postoperative surgical anatomy score was 1 (normal anus) in 24 patients, 2 in nine patients, which was not different significantly at follow up (p > 0.05). Postoperative bleeding required haemostasis in two patients. One patient had a stenosis temporarily, and two patients had persistent pain and faecal urgency, which disappeared. No sphincter lesions occurred. Control of symptoms and satisfaction were excellent in 20 patients, good in 11, and satisfactory in five. DISCUSSION: Stapled anopexy restored surgical anatomy towards normal, with moderate pain and few complications. Control of symptoms and patient-satisfaction was high. The procedure is a new option in the treatment of severe haemorrhoids rather than an alternative to open haemorrhoidectomy.

[Hemorrhoidectomy with stapler vs. traditional hemorrhoidectomy: comparative outcome of 2 groups of patients]

Gentile M, Cricri AM, D'Antonio D, Bucci L.

Dipartimento di Chirurgia Generale, Geriatrica, Oncologica e Tecnologie Avanzate Universita degli Studi di Napoli Federico II.

Ann Ital Chir. 2002 Mar-Apr; 73(2): 181-4; discussion 185-6. [Article in Italian]

Authors compare the results of two groups of patients, with III and IV degree haemorrhoids. The first group (48 patients) were treated with traditional surgery, open or closed. The second group (42 patients) treated with stapling haemorrhoidectomy. The groups were compared in order to determine if a true advantage exists regarding post-operative pain and functional recovery. Authors conclude that stapler haemorrhoidectomy, is somehow better in reducing the pain and offers a quick functional recovery. But the technique must be adopted in selected patients with mucosal prolapse, when the haemorrhoidal plexus is below the dentate line. In those cases, with inveterate mucosal prolapse, and thickened external fibrous tissue, or an irreducible prolapse of the external haemorrhoidal plexus, the choice must be carefully evaluated.

Risk factors associated with posthemorrhoidectomy secondary hemorrhage: a single-institution prospective study of 4,880 consecutive closed hemorrhoidectomies.

Chen HH, Wang JY, Changchien CR, Chen JS, Hsu KC, Chiang JM, Yeh CY, Tang R.

Colorectal Section, Chang Gung Memorial Hospital, Kao-Hsiung, Taiwan, Republic of China.

Dis Colon Rectum. 2002 Aug; 45(8): 1096-9.

PURPOSE: Posthemorrhoidectomy secondary hemorrhage is a rare but serious complication after hemorrhoidectomy. The determination of risk factors for this complication may provide information to improve outcome. A prospective study was conducted to determine the risk factors associated with posthemorrhoidectomy secondary hemorrhage. METHODS: We studied 4,880 patients who underwent an elective closed hemorrhoidectomy by 9 proctologists in a single institution between January 1994 and July 1996. The variables analyzed included age, gender, surgeon, surgeon's seniority, suture material, aseptic preparation, and use of antibiotics. The logistic regression model was used to assess the independent association of variables with posthemorrhoidectomy secondary hemorrhage. RESULTS: Among the 4,880 patients, 45 (0.9 percent) developed posthemorrhoidectomy secondary hemorrhage. The mean interval from operation to the onset of secondary hemorrhage was 8.8 (range, 5-19) days. Multivariate analysis revealed that patient's gender and individual surgeons were both independently associated with risk of hemorrhage. Male patients were more likely than females to develop posthemorrhoidectomy secondary hemorrhage (relative risk, 2.1; 95 percent confidence interval, 1.1-4.1; P = 0.021). The posthemorrhoidectomy secondary hemorrhage rates among individual surgeons ranged from 0.2 to 2.4 percent (P = 0.003). CONCLUSION: Our data suggest that male patients are more likely to develop posthemorrhoidectomy secondary hemorrhage than female patients and that intersurgeon variability is highly correlated with this risk.

[Our experience in the treatment of hemorrhoids and circumferential mucosal rectal prolapse using Longo muco-prolapsectomy ]

Trentin G, Agresta F, Mainente P, Ciardo L, Michelet I, Bedin N.

U.O. di Chirurgia Generale, Presidio Ospedaliero di Vittorio Veneto (TV), Azienda ULSS n. 7 della Regione Veneto.

Chir Ital. 2002 May-Jun; 54(3): 389-94. Related Articles, Links [Article in Italian]

The authors report their experience with the treatment of hemorrhoid disease and circumferential mucosal rectal prolapse with the use of a mechanical suturing device, according to the Longo technique. Over the period from March 98 to December 2000, 106 patients were treated with the above-mentioned procedure (100 patients for haemorrhoids and 6 for circumferential prolapse). Twenty-one patients had grade 4, 77 grade 3 and only 2 grade 2 disease. One hundred patients were followed up over a median period of 16.5 months (for the group with haemorrhoids) and 19 months (for the prolapse group). In 81% of cases the procedure was one-day surgery. Mucohaemorrhoidectomy with a stapler was well tolerated in terms of severity of postoperative symptomatology: in 42% of the patients operated on there was no need for any analgesic treatment. The time to return to work was 9.9 days for self-employed subjects and 15.6 days for the others. Refinement of the procedure and better patient selection may improve the results achieved with this technique. Stapled haemorrhoidectomy may be regarded as a sound technique that should be part of the surgeon's armamentarium. We suggest an "eclectic" approach whereby the stapling procedure may be included among the possible therapeutic options, with a view to optimising the choice of therapy for each individual patient.

[Surgical treatment of hemorrhoids]

Polovinkin VV, Savchenko IuP, Khmelik VI.

Khirurgiia (Mosk). 2002; (5): 54-9. [Article in Russian]

Since 1994 in addition to standard operations for chronic and acute hemorrhoids in Krasnodar military hospital the device for suturing in removal of internal hemorrhoids has been applied. From 1994 to 2000 examination and treatment of 240 patients with hemorrhoids were carried out. In the study group (128 patients) hemorrhoidectomy was performed by the developed method, in control (112 patients)--by standard techniques. In early postoperative period significantly smaller quantity of complications were seen in the study group (8.4%) compared with control group (29.8%). Decrease of hospital stay and out-patient treatment was also seen. Relapses of the disease were not revealed in terms from one to six years after surgery. The device may be employed in simultaneous operations when concomitant anorectal diseases are present. The above results justify one-stage operations in combination of chronic hemorrhoids with anorectal diseases. The proposed device makes this surgery easier.

Retroperitoneal sepsis complicating stapled hemorrhoidectomy: report of a case and review of the literature.

Maw A, Eu KW, Seow-Choen F.

Department of Colorectal Surgery, Singapore General Hospital, Singapore.

Dis Colon Rectum. 2002 Jun; 45(6): 826-8.

Stapled hemorrhoidectomy (mucosectomy) is a new technique that has recently been introduced for the treatment of third-degree and fourth-degree hemorrhoids and rectal mucosal prolapse. We present a case of severe retroperitoneal sepsis complicating stapled hemorrhoidectomy that was successfully treated by conservative means, further surgery therefore being avoided. The literature on the more serious complications associated with stapled hemorrhoidectomy is reviewed.

Double-blind, randomized trial comparing Harmonic Scalpel hemorrhoidectomy, bipolar scissors hemorrhoidectomy, and scissors excision: ligation technique.

Chung CC, Ha JP, Tai YP, Tsang WW, Li MK.

Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong Special Adminisrative Region, China.

Dis Colon Rectum. 2002 Jun; 45(6): 789-94.

PURPOSE: The aim of this study was to compare the outcome of patients receiving hemorrhoidectomy using Harmonic Scalpel, bipolar scissors, and the conventional scissors excision-ligation technique. METHODS: Eighty-six patients with irreducible prolapsing piles were randomly assigned to receive 1) Milligan-Morgan hemorrhoidectomy using scissors excision-ligation technique or 2) bipolar scissors hemorrhoidectomy and Harmonic Scalpel hemorrhoidectomy. Neither the patient nor the independent assessor were aware of the technique used at operation. Patients were followed up at 4 and 12 weeks after operation. The measured outcomes included 1) operation time; 2) blood loss; 3) postoperative hospital stay; 4) pain score; 5) pain expectation score; 6) date of first bowel movement; 7) number of pethidine injections; 8) number of dologesic tablets taken; 9) time off work or normal activity; 10) wound healing; 11) satisfaction score; and 12) postoperative complications, including anal stenosis and fecal or flatus incontinence. RESULTS: There was no difference among the three groups in the operation time, hospital stay, pain expectation score, day of first bowel movement, number of dologesic tablets taken, time off work or normal activity, wound healing, and satisfaction score. The complication rate also did not differ in the three groups. Both Harmonic Scalpel hemorrhoidectomy and bipolar scissors hemorrhoidectomy were superior to Milligan-Morgan hemorrhoidectomy in terms of reduced blood loss. Harmonic Scalpel hemorrhoidectomy had the best pain score when compared with bipolar scissors hemorrhoidectomy and Milligan-Morgan hemorrhoidectomy, and patients required significantly less pethidine injection after Harmonic Scalpel hemorrhoidectomy than after Milligan-Morgan hemorrhoidectomy. Although the time required to return to work or normal activity remained similar, patients after Harmonic Scalpel hemorrhoidectomy had the best satisfaction score among the three groups. CONCLUSION: The study shows that Harmonic Scalpel hemorrhoidectomy is as good as bipolar scissors hemorrhoidectomy in terms of reduced blood loss but is superior because it is associated with less postoperative pain and hence, better patient satisfaction. However, these observed benefits are small, and the time off work or normal activity remains similar.

Modified Longo's hemorrhoidectomy.

Lloyd D, Ho KS, Seow-Choen F.

Department of Colorectal Surgery, Singapore General Hospital.

Dis Colon Rectum. 2002 Mar; 45(3): 416-7.

The Longo technique of stapled hemorrhoidectomy is rapidly gaining world-wide acceptance. However, hemorrhoids with large external components are often left with troublesome skin tags after the Longo technique. In this article we present modifications to the Longo technique that make it easier to perform and provide adequate treatment of hemorrhoids that have a significant external component or skin tags.

Early experience with stapled hemorrhoidectomy in the United States.

Singer MA, Cintron JR, Fleshman JW, Chaudhry V, Birnbaum EH, Read TE, Spitz JS, Abcarian H.

Department of Surgery, University of Illinois, Chicago 60612, USA.

Dis Colon Rectum. 2002 Mar; 45(3): 360-7; discussion 367-9.

INTRODUCTION: We report the early results of patients treated with stapled hemorrhoidectomy, which has recently been introduced into the United States. METHODS: Sixty-eight patients with symptomatic hemorrhoids were treated at two institutions with the Proximate HCS Hemorrhoidal Circular Stapler supplied by Ethicon Endo-Surgery. Patients were prospectively evaluated for functional recovery and postoperative pain on a 1 to 10 scale. RESULTS: There were 45 (66 percent) males and 23 (34 percent) females with a mean age of 56 years and median duration of symptoms of 5 years. The mean operative time was 22.2 minutes. The operation was performed with spinal (50 percent), local (40 percent), or general (10 percent) anesthesia and as an outpatient (56 percent) or overnight admission (44 percent). Ninety-three percent of patients remained asymptomatic with a mean follow-up of 34 weeks, whereas the remaining 7 percent required either surgical excision or rubber band ligation for persistent symptoms. There was no mortality, new incontinence, fecal impaction, or persistent pain. The total morbidity was 19 percent, with urinary retention as the most common complication (12 percent). The mean pain score decreased from 3.6 on postoperative Day 1 to 1.4 at postoperative Day 7. Ninety-nine percent of patients made a complete functional recovery by postoperative Day 7. CONCLUSIONS: Stapled hemorrhoidectomy is safe, effective, and can be performed as an outpatient procedure with local or regional anesthesia. There seems to be minimal postoperative pain and early recovery, although a benefit over traditional hemorrhoidectomy needs to be proven in a randomized trial.