Scientific Articles on Hemorrhoidectomy - 2003 & 2004

Can the procedure for prolapsing hemorrhoids (PPH) be done twice? Results of a porcine model.

Zmora O, Colquhoun P, Abramson S, Weiss EG, Efron J, Vernava AM 3rd, Nogueras JJ, Wexner SD.

Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA.

Surg Endosc. 2004 Jan 23

Background: The procedure for prolapsing hemorrhoids (PPH) is a new surgical method for the treatment of symptomatic hemorrhoids. In cases of recurrent prolapse, the performance of a second PPH may result in a ring of mucosa and submucosa between the two circular staple lines. In this study, we used a porcine model to assess whether PPH can be safely performed twice. Methods: Five adult pigs underwent two PPH procedures in one session, leaving a ring of ~1 cm of mucosa between the two staple lines. One month later, the pigs were examined under anesthesia. The anal canal was assessed using the following four methods: (a) clinical examination, (b) evaluation of mucosal blood perfusion at different levels of the anal canal via a laser Doppler flow detector, (c) measurement of concentrations of hydroxyproline and collagen to check for fibrosis, and (d) histopathological examination. Results: At the completion of the study period, all five pigs showed no clinical evidence of anorectal dysfunction. On examination under anesthesia 1 month after surgery, there was no evidence of anal stenosis in any of the pigs. The mean mucosal blood flow between the two staple lines did not differ significantly from the flow measured proximally and distally (394 vs 363 and 339 flow units, respectively; p = NS). The collagen levels, based on hydroxyproline concentration, were 81 mcg/mg between the staple lines, compared to 82 and 79 proximally and distally, respectively ( p = NS). There was no significant difference in degree of fibrosis, as assessed histopathologically, between specimens taken from the ring between the staple lines and specimens taken from the area external to the staple lines. Conclusions: The results of this porcine model suggest that a second synchronous PPH is feasible. A controlled experience involving human subjects is required to determine the safety and usefulness of this technique in cases of metachronous application for recurrent or residual hemorrhoids.

[Treatment of prolapsed hemorrhoids with circular stapler]

Zhang SM, Yang DL, Song HF, Li XB, Lin GL, Li JY.

Department of General Surgery, Peking Union Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100032, China.

Zhonghua Wai Ke Za Zhi. 2003 Nov; 41(11): 815-6. [Article in Chinese]

OBJECTIVE: To evaluate the efficacy and safety of circumferential mucosectomy procedure for treatment of prolapsed hemorrhoids (PPH). METHODS: From June 2001 to June 2003, 74 patients (27 men and 47 women) with an average age of 57 years (ranging from 31 to 80 years), with prolapsed hemorrhoids III approximately IV degree underwent PPH using a circular stapler. RESULTS: 69 (93.2%) patients were fully satisfied with results. Two patients underwent simultaneous rectal polypectomy along with PPH hence required analgesic treatment for 5 days. Three patients experienced bleeding during or after operation, 1 case bleeding was due to ulcerative hemorrhoid, while the bleeding the remaining 2 cases was (bleeding about 300 ml) caused by insufficient anastomosis, thus extending operating time to 1 hour. The average operation time (70 patients) was 13 minutes (range 10 approximately 15 minutes). The mean hospitalization was 3.5 days (2 approximately 4 days), with exception of 2 patients lasting 1 week. CONCLUSION: PPH is a safe, effective and rapid method for treatment of prolapsed hemorrhoids, The procedure causes minimal pain with decreased complications.

Stapled hemorrhoidectomy: surgical notes and results.

Mascagni D, Zeri KP, Di Matteo FM, Peparini N, Maturo A, Berni A.

Department of Surgical, Sciences, La Sapienza University, Rome, Italy.

Hepatogastroenterology. 2003 Nov-Dec; 50(54): 1878-82.

Recently the surgical treatment of hemorrhoids using a circular stapler device has gained increasing approval. The Longo's procedure reduces the rectal mucosal and hemorrhoid prolapse using a circular stapler to resect transversally a mucosal-submucosal rectal ring in order to restore the correct anatomical relationships of the anal canal structures. The recent availability of a dedicated instrument kit (PPH01 Ethicon Endo-Surgery) allowed an easy diffusion of this technique. From March 1999 to September 2001, 198 patients with III-IV degree hemorrhoids were treated by a single expert surgeon using the dedicated kit instrumentation (PPH01) according to the Longo's technique, adopting some variations from the original procedure: 1) The anal dilator is not fixed to the perianal skin with forceps or stitches but is kept by the assistant. 2) In performing the purse-string suture particular care must be given to the apposition of the stitches at the same level also in the posterolateral side where there is a natural trend to apply the stitches at a lower level; furthermore the last stitch of the purse-string suture must be overlapped to the first one in order to allow a better hemostasis when the knot is tightened. 3) After having performed the purse-string and having resected the mucosa and submucosa, an accurate hemostasis with U-shaped 3/0 vicryl stitches firmly reduces the postoperative bleeding. We recorded pain scores, short- and long-term complications (included moderate-severe pain, persistent pain), recurrences and postoperative hospital stay. The data of the last 40 consecutive patients who underwent stapled hemorrhoidectomy were compared with the data obtained by 40 consecutive patients who underwent Milligan-Morgan diathermic hemorrhoidectomy for III-IV degree non-circumferential hemorrhoids by the same surgeon. In the 198 stapled hemorrhoidectomy cases the rate of postoperative moderate-severe pain and persistent pain were 6% and 2.5% respectively, the rate of short-term and long-term bleeding were 4.5% and 3.5%, the recurrence rate was 2.5%. The mean postoperative stay was 1.6 days. The stapled group had significantly lower postoperative moderate-severe pain, bleeding and soiling than the Milligan-Morgan group.

Complications and results after stapled haemorrhoidopexy as a day surgical procedure.

Mlakar B, Kosorok P.

Medical Centre IATROS, Parmova 51b, 1000 Ljubljana, Slovenia. bmlakardobnik@hotmail.com

Tech Coloproctol. 2003 Oct; 7(3): 164-7; discussion 167-8.

BACKGROUND: The aim of this report is to describe our experience with stapled haemorrhoidopexy as a day surgery procedure. METHODS: From January 2000 to January 2003, a total of 214 patients with third- and fourth-degree haemorrhoids underwent stapled haemorrhoidopexy under spinal anaesthesia. We analysed early postoperative complications and long-term results. Patients were followed for 4-36 months (mean, 22 months). Only 3 patients (1%) were hospitalised. The long-term complications were analysed by means of a mailed questionnaire. RESULTS: Minor bleeding at wiping after defecation was observed by 9% of patients and minor haemorrhoidal prolapse by 8% of patients. Pain after defecation was reported by 6% of patients and anal stenosis occurred in 2% of them. Faecal urgency was reported by 3% of patients with previously unknown incontinence problems. CONCLUSION: According to our experience, stapled haemorrhoidopexy can be safely performed as a day surgery procedure.

Surgical treatment of haemorrhoids according to Longo and Milligan Morgan: an evaluation of postoperative tissue response.

Krska Z, Kvasnieka J, Faltyn J, Schmidt D, Svab J, Kormanova K, Hubik J.

Department of Surgery, Charles University, Prague, Czech Republic.

Colorectal Dis. 2003 Nov; 5(6): 573-6.

OBJECTIVES: To compare by prospective randomised trial the postoperative tissue reaction of stapled vs. conventional haemorrhoidectomy. PATIENTS AND METHODS: Fifty patients with stage III haemorrhoids underwent surgery for haemorrhoids. Group 1 (n = 25) had the Milligan-Morgan procedure; Group 2 (n = 25) had a stapled haemorrhoidectomy. All patients underwent measurements of endothelial dysfunction markers including E-selectin, P-selectin and intercellular adhesion molecule (ICAM). Acute-phase proteins including C-reactive protein, orosomucoid and fibrinogen were also measured. Estimations were made prior to surgery, immediately afterward surgery and on the first and fifth postoperative days. Assessment of clinical outcome was made one month after the surgery. RESULTS: There was a postoperative increase of acute-phase reactants in both groups. The patterns of the cures of the monitored parameters appeared similar in both groups. Lower values were found in Group 1, but the difference was not statistically significant except the level of fibrinogen on day 5, which was significantly higher in Group 2. E-selectin, P-selectin and ICAM showed similar time curves. Statistical analysis found the differences to be significant only when individual days were compared and not for the types of surgery. Raised ICAM and P-selectin on the fifth postoperative day was found in both groups. In Group 1, pain assessment by patients remained in the lower part of the pain rating scale, while in Group 2 it did not start declining until one week after surgery and became normal in the third to fourth weeks. In Group 1, the duration of hospitalization and the duration of incapacity for work were 50% of the values in Group 2. CONCLUSION: Patients having stapled haemorrhoidectomy have less pain and experience more rapid recovery when compared to classical haemorroidectomy. This was mirrored by the acute-phase protein CRP and fibrinogen levels postoperatively. There was no significant difference in other acute-phase reactants monitored, nor was there any difference in parameters of endothelial dysfunction. The techniques differ in extent of pain and duration of hospital stay and incapacity for work.

Randomized trial comparing in-situ radiofrequency ablation and Milligan-Morgan hemorrhoidectomy in prolapsing hemorrhoids.

J Gupta P.

Consulting Proctologist, Fine Morning Hospital and Research Center, Gupta Nursing Home, India. drpjg@yahoo.co.in

J Nippon Med Sch. 2003 Oct; 70(5): 393-400.

The Milligan-Morgan (MM) operation is the most widely practiced procedure for prolapsed hemorrhoids. But it is also associated with a fair amount of postoperative pain, a long period of convalescence, and complications like bleeding and anal stenosis. The aim of this study was to evaluate the efficacy of in-situ radiofrequency ablation (RA) of hemorrhoids. During a 6-month period, 40 patients with grade 3 hemorrhoids were prospectively randomized for RA (21 patients) or MM hemorrhoidectomy (19 patients). Patients were evaluated for operative time, postoperative pain, time to return to work and occurrence of early and late complications. Duration of surgery was significantly higher in the MM group (p<0.0001). Postoperative hospitalization was longer in the MM group (p<0.001). The post defecation pain and pain at rest were much less in the RA group (p<0.001). Wound healing period (16.3 vs. 37.5 days) and time to return to work (7.3 vs. 18.3 days) were other significant findings. Early complications occurred more frequently in the MM group, but late complications like external skin tags [4 patients vs. 2 patients] and one asymptomatic recurrence was noted in the RA group. In-situ RA of prolapsing hemorrhoids is a quick and bloodless procedure. It is associated with significantly less postoperative pain, shorter hospital stay and early return to normal activity. It can be considered as an alternative to conventional hemorrhoidectomy.

Stapled hemorrhoidectomy: a review of our early experience.

Dixon MR, Stamos MJ, Grant SR, Kumar RR, Ko CY, Williams RA, Arnell TD.

Department of Surgery, Division of Colorectal Surgery, Harbor-UCLA Medical Center, Torrance, California, USA.

Am Surg. 2003 Oct; 69(10): 862-5.

Treatment of hemorrhoids may safely be accomplished by using a circular stapler instead of the conventional open procedure for large symptomatic hemorrhoids. Our purpose was to assess the safety and early post-op results of this new surgical technique as it was introduced into clinical practice. Medical records from 62 patients treated by circumferential mucosectomy/stapled hemorrhoidectomy were obtained from 6 surgeons. Preoperative factors assessed included demographics, comorbidities, prior anorectal surgery, hemorrhoid grade, and the indications for surgery. Operative factors examined included operating time, use of perioperative antibiotics, and oversewing of the suture line. Postoperative factors included complications and date of last follow-up. Sixty-two patients underwent this operation, and complications were reported in six patients (10%). There was one death unrelated to the hemorrhoid surgery. Postoperative pain, defined as requiring pain control with intravenous medication, hospital admission, or an emergency department visit, occurred in two patients. Two patients reported postoperative bleeding. One patient experienced bleeding the first evening, and the second patient had bleeding 1 week postoperatively. The first patient was admitted overnight and required no blood transfusion or further intervention. The second patient was subsequently found to have a bleeding diverticulum. One patient experienced urinary retention that resolved with conservative management. Postoperative follow-up was available for over 90 per cent of the patients at a median of 4 weeks postoperatively. No additional complications were discovered at follow-up. This data suggests that stapled hemorrhoidectomy is a safe and effective approach to hemorrhoidal disease. Our findings indicate an acceptable complication rate among a group of surgeons beginning to integrate this modality into clinical practice.

Circumferential mucosectomy with stapled proctopexy is a safe, effective outpatient alternative for the treatment of symptomatic prolapsing hemorrhoids in the elderly.

Johnson DB, DiSiena MR, Fanelli RD.

Residency Program in General Surgery, Berkshire Medical Center, 725 North Street, Pittsfield, MA 01201, USA.

Surg Endosc. 2003 Oct 23

Background: Circumferential mucosectomy with stapled proctopexy (CMSP) was first introduced in 1993 as a less painful and highly effective alternative to traditional operative hemorrhoidectomy. Although CMSP has many advantages over traditional hemorrhoidectomy, some authorities and insurers continue to regard it as an inpatient procedure and others have been slow to adopt this progressive technique. This study documents the safe and effective outpatient nature of this procedure. Methods: From December 2001 through August 2002, 33 patients with mucosal prolapse and prolapsing internal hemorrhoids were treated using circumferential mucosectomy with stapled proctopexy as outpatients at an ambulatory surgery center. Fourteen (42%) patients were treated using local anesthesia with intravenous sedation, 18 (55%) chose spinal anesthesia, and general anesthesia was used in one patient. Patients were evaluated postoperatively by telephone at 1 and 2 weeks, and seen in clinic at 4 weeks. Results: One patient (3%) required an emergency department visit for minor postoperative bleeding. None of our elderly patients required emergency department evaluation and none reported significant complications. Four patients (13%) required urinary catheter placement prior to discharge from the surgery center due to urinary retention. One patient (3%) developed an uncomplicated urinary tract infection, which resolved with antibiotic treatment. Two patients were seen earlier than 4 weeks at the surgeon's request; one was immunocompromised from chemotherapy for metastatic carcinoid, and one reported persistent pain during initial telephone follow-up. No complications were identified in either patient, and no additional complications have been noted to date. Conclusions: CMSP is a safe, effective, time-efficient procedure for patients with mucosal prolapse and prolapsing hemorrhoids that can be performed safely in the ambulatory surgery center setting. Age is not a limiting factor in selecting patients for this safe outpatient procedure.

[Stapled hemorrhoidectomy--early experience in 30 patients]

Amosi D, Werbin N, Kashtan H, Skornik Y, Greenberg R.

Department of Surgery A, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Harefuah. 2003 Oct; 142(10): 654-8, 720. [Article in Hebrew]

INTRODUCTION: We report the early results of 30 patients treated by stapled hemorrhoidectomy. PATIENTS AND METHODS: Thirty patients with symptomatic grade 2-4 hemorrhoids were treated by stapled hemorrhoidectomy. The procedure was performed with a 33 mm diameter automatic hemorrhoidal circular stapler. The patients were prospectively evaluated for immediate and functional recovery, postoperative pain and subjective success of the treatment. RESULTS: The median age of the patients was 46.2 years, and the median duration of the symptoms was 27 months. The main symptom was bleeding (in 96% of the patients). The average operative time was 22 minutes. The operation was performed with spinal (63.3%) or general (36.7%) anesthesia. There was no mortality, urinary retention, incontinence, fecal urgency or persistent pain. One patient, who was under anticoagulant treatment, had postoperative bleeding, which required transfusion of 3 units of blood, and another patient was operated on because of perforation of the sigmoid colon. Most patients (twenty eight) had complete functional recovery and returned to their usual daily activities within 10.4 days. Postoperative pain and subjective success were evaluated by a 1 to 10 scale. The average pain score decreased from 5.8 on the first postoperative day to 2.4 on the 7th postoperative day. The average satisfactory score was 9.2. CONCLUSION: Stapled hemorrhoidectomy is an alternative to conventional surgical hemorrhoidectomy. The procedure seems to be associated with less postoperative pain and early recovery with a high satisfaction rate among patients.

[New modalities and concepts in the treatment of hemorrhoids]

Hetzer FH, Wildi S, Demartines N.

Klinik fur Viszeral- und Transplantationschirurgie, Universitatsspital Zurich.

Schweiz Rundsch Med Prax. 2003 Sep 17; 92(38): 1579-83. [Article in German]

The surgical treatment of haemorrhoids has significantly changed by introducing new techniques in the last years. Nowadays, low grade haemorrhoids, grade II and III, are easily and painfree treatable by a minimal invasive, Doppler transducer guided ligation of the haemorrhoidal arteries. In cases of circular protruding haemorrhoids, grade III and IV; the stapled mucosectomy described by Longo is also a new effective treatment. Both procedures can be performed for an outpatient or with short hospital stay and allows patients to return to work earlier compared to conventional techniques. Additionally, due to the new techniques the treatment of haemorrhoids is less painful and has increased patients' satisfaction. Therefore, the traditional haemorrhoidectomy, the Milligan-Morgan or the Ferguson procedure, has become less common and is only performed in a few special indications.

Stapled hemorrhoidectomy for the treatment of hemorrhoids.

Nahas SC, Borba MR, Brochado MC, Marques CF, Nahas CS, Miotto-Neto B.

Hospital S rio Liban s.

Arq Gastroenterol. 2004 Jan-Mar; 40(1): 35-9. Epub 2003 Oct 06.

BACKGROUND: The use of circular staplers in the treatment of hemorrhoidal disease is known as a simple procedure, with low morbidity, less post-treatment pain and with the same efficacy when compared to the classical hemorrhoidectomy. AIM: Analyze the operative technique, intra-operative and immediate postoperative complications and late results in 100 patients treated for hemorrhoid disease by stapling technique. PATIENTS AND METHODS: The group included 53 males and 47 females with mean age of 49.8 years, operated during the period June 2000 to June 2002 in the "Hospital Universit rio" (S o Paulo University Hospital) and "Hospital S rio Liban s", in S o Paulo, SP, Brazil. RESULTS: The majority of patients (78%) were discharged on the first post-operative day. Eight patients required supplementary analgesia and were given intramuscular diclofenac sodium and four of them received intramuscular tramadol. One intraoperative complication was bleeding which was difficult to control and required a blood transfusion. One patient was reoperated on the first postoperative day due to intermittent and persistent bleeding, however without hemodynamic changes or a drop in hematocrit. Two patients presented hemorrhoidal thrombosis in the early postoperative stage. The postoperative follow-up displayed: recurrence of prolapse, five cases (5%); anal sub-stenosis, two cases (2%); anal fissure, one case (1%); persistent pain, two cases (2%). Seven reoperations were performed: one due to bleeding, one due to sub-stenosis and five due to recurrence of hemorrhoidal prolapse and persistence of symptoms. CONCLUSIONS: Stapling is simple to accomplish, has low postoperative pain and rate of complications, however, the incidence of late reoperations is rather high and therefore major follow-up for better analysis is required.

[Choice of hemorrhoidectomy method in chronic hemorrhoid]

Shelygin IuA, Blagodarnyi LA, Khmylov LM.

Khirurgiia (Mosk). 2003; (8): 39-45. [Article in Russian]

Seventy patients with hemorrhoid of stage III-IV underwent surgery. In the study group (n = 21) hemorrhoidectomy was performed with ultrasonic knife. In control group 1 (n = 22) closed hemorrhoidectomy with recovery of anal canal mucosa was performed, in control group 2 (n = 27)--standard open hemorrhoidectomy with electrocoagulation. When ultrasonic knife was used, time of surgery reduced significantly compared with standard closed and opened hemorrhoidectomy--14.7 +/- 3.7, 40.2 +/- 6.5 and 32.5 +/- 5.6 min respectively (p < 0.05). On day 1 after surgery intensive pains were seen more rarely in patients of the study group compared with ones of both control groups (34, 75 and 66% patients respectively). In subsequent days intensive pains were seen also more rarely in study group than in control groups: on day 3 in 15, 40 and 35 patients, respectively, on day 7 in 5, 30 and 20 patients, respectively (p < 0.05). Degree of pain syndrome on day 1 after surgery in the study and control groups was 3.0 +/- 0.4, 7.0 +/- 0.2 and 6.0 +/- 0.3 points, respectively (p < 0.05). Patients of the study group demonstrated low requirement in narcotic and non-narcotic analgesics compared with the other groups. The time of postoperative rehabilitation of patients in the study and control groups was 12.3 +/- 2.4, 18.5 +/- 3.8 and 20.1 +/- 4.4 days, respectively (p < 0.05).

Stapled hemorrhoidectomy: initial experience of a Latin American group.

Habr-Gama A, e Sous AH Jr, Rovelo JM, Souza JV, Benicio F, Regadas FS, Wainstein C, da Cunha TM, Marques CF, Bonardi R, Ramos JR, Pandini LC, Kiss D.

Department of Gastroenterology, University of Sao Paulo Medical School, Sao Paulo, Brazil.

J Gastrointest Surg. 2003 Sep-Oct; 7(6): 809-13.

The purpose of the present study was to determine the value of circular hemorrhoidectomy (procedure for prolapse and hemorrhoids [PPH]) on the basis of data collected prospectively during the initial experience of a group of Latin American surgeons. Between 2000 and 2001, PPH was performed using a circular stapler in 177 patients who had third- and fourth-degree hemorrhoidal disease. The average age of the patients was 47.7 years (range 26 to 85 years). Anal bleeding was the most common preoperative complaint (93.2%) followed by anal pain (60.2%), anal itching (43%), and constipation (41%). Hemorrhoids were classified as third degree in 132 patients (74%) and fourth degree in 45 patients (25.4%). Skin tags were detected in 86 patients (48.8%) and rectocele in 14 patients (7.9%). Data collected included patient demographics, type of anesthesia, and specific details of the surgery such as duration of the operation, distance from the staple line to the dentate line, need for complementary hemostasis, and any unexpected occurrences. Postoperative data collected included the degree of pain, which was evaluated on the basis of the type and dosage of analgesics required, laxative consumption, and the presence of bleeding, fever, urinary retention, or hematomas. Each patient completed a written questionnaire addressing these events. Patients returned for follow-up visits on days 7, 15, 30, and 90. Responses to pain, bleeding, fever, anal continence, recurrence of hemorrhoids, and level of satisfaction were compiled. The duration of the procedure ranged from 6 minutes to 2 hours (average 23 minutes), and most operations lasted no more than 20 minutes, with the exception of one that lasted 2 hours because of intraoperative bleeding. Intraoperative problems were minor. An additional one or a few sutures were required in 58.7% of patients to achieve perfect hemostasis. In 128 patients (72.3%) the hospital stay was less than 24 hours. Same-day surgery was chosen for 37 patients (20.9%). Pain was controlled with analgesia only using one to six doses of oral dipirona in 126 patients. Five patients were readmitted to the hospital: four for control of bleeding and one for conventional hemorrhoidectomy due to an acute episode of external hemorrhoidal thrombosis. At day 30, patients rated the efficacy of the procedure in alleviating preoperative symptoms as follows: 77.5% excellent; 16% good; 5.3% average, and 1.2% poor. At 3 months postoperatively no patient had had a recurrence of hemorrhoidal prolapse, and there were no instances of stenosis or anal incontinence. Surgeons also rated the efficacy of the procedure as excellent in 75%, good in 19.8%, average in 4.7%, and poor in 0.6%. With proper selection of patients and adequate stapling technique, stapled hemorrhoidectomy may be considered safe; it is easily learned, has a satisfactory degree of pain, and is well accepted by both patients and surgeons.

Excision of thrombosed external hemorrhoid under local anesthesia: a retrospective evaluation of 340 patients.

Jongen J, Bach S, Stubinger SH, Bock JU.

Proctological Office and Department of Surgical Proctology, Park-Klinik, Kiel, Germany.

Dis Colon Rectum. 2003 Sep; 46(9): 1226-31.

PURPOSE: This study was a retrospective analysis of complication rates, symptom recurrence, long-term results, and patient satisfaction after outpatient excision (local anesthesia) of thrombosed external hemorrhoids. METHODS: From 1995 to 2000, 340 patients (166 males) underwent office-based excision of thrombosed external hemorrhoids under local anesthesia. Data regarding complications, operations because of recurrence, residual symptoms, patient's satisfaction with anesthesia, and wound treatment were obtained by questionnaire. Response was solicited at a minimum of 9 months postprocedure. RESULTS: Complete follow-up data was available in 88 percent of patients (mean follow-up, 17.3 months). Recurrent thrombosed external hemorrhoid requiring a procedure developed in 22 (6.5 percent) patients. Other complications that required operative intervention were one (0.3 percent) incidence of postoperative bleeding and seven (2.1 percent) perianal abscess/fistula. The majority of patients (66 percent) had no anal complaints at follow-up. Local anesthesia would be preferred if a repeat excision was required in 79 percent, whereas 11 percent would prefer another form of anesthesia and 10 percent were unsure. CONCLUSION: Outpatient excision under local anesthesia of a thrombosed external hemorrhoid can be safely performed with a low recurrence and complication rate while offering a high level of patient of acceptance and satisfaction.

Epidural anesthesia does not increase the incidences of urinary retention and hesitancy in micturition after ambulatory hemorrhoidectomy.

Kau YC, Lee YH, Li JY, Chen C, Wong SY, Wong TK.

Department of Anesthesiology, Chang Gung Memorial Hospital, 5 Fu-Shin Street, Kweishan, Taoyuan, Taiwan, R.O.C.

Acta Anaesthesiol Sin. 2003 Jun; 41(2): 61-4.

BACKGROUND: This randomized, prospective study was designed to evaluate the role of various anesthesias in postoperative urinary retention and hesitancy in micturition in patients receiving hemorrhoidectomy on ambulatory basis. METHODS: In a randomized order, 128 ambulatory patients, ASA physical status I or II, were divided into two groups to receive hemorrhoidectomy under epidural or local anesthesia. In all patients, the intraoperative intravenous fluid given was limited to 200 ml +/- 2 ml/kg/h of Ringer's lactate solution. Patients were requested to void urine voluntarily before discharge. The incidences of postoperative urinary retention and hesitancy in micturition were evaluated by telephone interview 24 hours after surgery. RESULTS: Neither the incidence of urinary retention, nor the incidence of hesitancy in micturition was significantly different between the two groups. Patients with age over 50 had a significantly higher incidence of hesitancy in micturition than younger patients. The incidence of hesitancy in micturition seemed higher in male patients (31.3%) than that in females (15.6%), but the difference was not statistically different (P = 0.0585). CONCLUSIONS: With judicious intraoperative fluid restriction and voluntary voiding before discharge, epidural anesthesia does not increase the incidence of postoperative urinary retention or hesitancy in micturition following ambulatory hemorrhoidectomy.

[Surgery of hemorrhoids using the Long method and its complications]

Hahn M, Simsa J, Horak J.

Chirurgicko-traumatologicke oddeleni Klaudianovy nemocnice, Sdruzeni zdravotnickych zarizeni Mlada Boleslav.

Rozhl Chir. 2003 Jun; 82(6): 307-11. [Article in Czech]

BACKGROUND: The aim of this article is an assessment of new surgical procedure--stapled hemorroidectomy according to Longo. We do concentrate on surgical complications and possibilities of it's management. METHODS: Prospective, clinical follow up of patients in which stapled hemorrhoidectomy was performed during the period of 2 years (1st December 2000--30st November 2002). Observation concentrates on surgical complications of this method. All patients had a clinical check up 3 weeks and 3 months after surgery. In case of any problems treatment and follow up continues. RESULTS: Stapled hemorroidectomy was performed during the period of 2 years in 52 patients (100%). There was 11 patients (21.2%) with some of surgical complication. The most serious one was massive rectal bleeding after surgery, which has been observed in 4 patients (7.6%). Other surgical complications observed in our group were anal stenosis, local infection, acute anal fissure and retention of urine. CONCLUSION: Stapled hemorroidectomy is now one of feasible alternatives for surgical treatment of hemorrhoids. Serious surgical complications observed in our patients were bleeding from the stapled suture line and anal stenosis. The aim of this article is to refer possible surgical complications of this method, it's prevention and management.

[Surgical treatment of mucosal hemorrhoidal prolapse using a circular stapler]

Zanghi G, Catalano F, Zanghi A, Gangi S, Furci M, Basile G, Benfatto G, Basile F.

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

Ann Ital Chir. 2003; 74(1): 63-5; discussion 66. [Article in Italian]

We present a retrospective clinical study concerning our personal experience with the circular stapler in the treatment of hemorrhoids; the aim of this study was to evaluate the results of this surgical procedure, in terms of operative time, postoperative pain and rate of both short and long-term complications. Twenty-seven patients with grade 3 or 4 hemorrhoids, from January 1999 to June 2001, were included in the study. The main technical details of this procedure, requiring only a short learning period, are described and both short-term complications (such as severe postoperative pain, bleeding, urinary and fecal retention) and long-term ones (such as persistent or recurrent haemorrhoidal prolapse, anal stenosis) are analyzed. The reported results show that, in the presence of appropriate local anatomic conditions, this procedure is able to reduce the operative time, is almost painless and is characterized by low rate of complications.

Stapled haemorrhoidopexy: a consensus position paper by an international working party - indications, contra-indications and technique.

Corman ML, Gravie JF, Hager T, Loudon MA, Mascagni D, Nystrom PO, Seow-Choen F, Abcarian H, Marcello P, Weiss E, Longo A.

Department of Surgery, North Shore-Long Island Jewish Medical Center, NewHyde Park, New York 11040, USA. mcorman@lij.edu

Colorectal Dis. 2003 Jul; 5(4): 304-10.

An international working party with experience in the performance of an alternative haemorrhoid operation through the use of the circular stapler was convened for the purpose of developing a consensus as to the criteria for undertaking this procedure. The agenda consisted of first, naming the operation; second, the indications and contra-indications for its performance; and third, the preferred surgical technique. Among the recommendations for individuals who plan to embark on this surgery are that experience with anorectal surgery and an understanding of anorectal anatomy are requisites; experience with circular stapling devices is essential; and the surgeon must attend a formal course which should include lectures, videos, the application of the instrument in models, and observation of the operation as performed by a surgeon recognized by his or her peers-leading ultimately to undertaking the procedure while being observed by an experienced surgeon. Following satisfactory completion of the above, independent responsibility should be determined by an individual's department of surgery.

Stapled anoplasty for haemorrhoids: a comparison of ambulatory vs. in-patient procedures.

Guy RJ, Ng CE, Eu KW.

Department of Colorectal Surgery, Singapore General Hospital, Outram Road, Singapore 169608.

Colorectal Dis. 2003 Jan; 5(1): 29-32.

OBJECTIVE: Haemorrhoids are commonly seen in colorectal practice. Stapled anoplasty is a novel approach to the treatment of this condition and is usually performed as an in-patient procedure. The aim of this study was to investigate the suitability of this technique for ambulatory surgery. PATIENTS AND METHODS: Fifty consecutive patients undergoing stapled anoplasty under general anaesthesia as day cases (DC) (mean age 41 years; 27 females) by a single consultant surgeon over a 12-month period were compared with 50 consecutive patients undergoing the same procedure as in-patients (mean age 44 years; 25 females) (IP) during the same period. RESULTS: Eight DC patients (16%) were admitted overnight from the day surgery unit for urinary retention (3), pain (2), bleeding (2) and anaesthetic reasons (1). Three other DC patients were re-admitted after a mean period of 4 days with bleeding (2), one of which required surgical haemostasis, and a septic complication (1). Mean hospital stay for IP cases was 2.6 (range 1-9) days. Two IP cases were re-admitted after 4 and 11 days for bleeding and wound infection, respectively. At review 2-4 weeks after discharge, satisfaction in both groups was high. Minor staple-line strictures were seen in 1 DC and 2 IP cases but all were easily dilated digitally. Mean costs incurred were significantly less for day surgery patients. CONCLUSIONS: Stapled anoplasty is suitable for use in day-case surgery as it is a quick and relatively painless procedure. The advantages, particularly financial, support the technique for use in an ambulatory setting, preferably in the morning, and provided detailed patient advice is given.

Stapled versus excision haemorrhoidectomy: long-term follow up of a randomised controlled trial.

Smyth EF, Baker RP, Wilken BJ, Hartley JE, White TJ, Monson JR.

Academic Surgical Unit, University of Hull, Castle Hill Hospital, Castle Road, HU16 5JQ, Cottingham, UK.

Lancet. 2003 Apr 26; 361(9367): 1437-8.

Advantages of the stapling procedure for haemorrhoids include reduced postoperative pain and shortened convalescence; however, there are few data with respect to functional and symptomatic outcome. At a dedicated clinic, we reviewed patients between Dec, 2001, and March, 2002, who had taken part in a randomised controlled trial undertaken at the unit in 1999, which compared outcomes after open or stapled haemorrhoidectomy. We noted the presence or absence of haemorrhoid specific symptoms, and assessed overall satisfaction, continence, and quality of life. Rigid sigmoidoscopy and an anorectal examination were also used to examine symptomatic recurrence and disease activity. At minimum follow-up of 33 months since surgery, both techniques seem to be equally effective.

Anal cushion resection versus Milligan-Morgan hemorrhoidectomy for circular hemorrhoids: randomized controlled trial.

Chen JF, Huang ZH, Chen YX, Xiao JQ.

Department of General Surgery, Zhujiang Hospital, First Military Medical University, Guangzhou 510282, China. cjf.fimmu@eyou.com

Di Yi Jun Yi Da Xue Xue Bao. 2003 Apr; 23(4): 382-3, 386.

OBJECTIVE: To compare the clinical effect of anal cushion resection with Milligan-Morgan hemorrhoidectomy for the third- or fourth-degree circular hemorrhoids. METHODS: Forty-eight patients with third- or fourth-degree circular hemorrhoids were randomly assigned into two groups to receive either anal cushion resection or Milligan-Morgan hemorrhoidectomy. Comparison of the two approaches were conducted in terms of postoperative pain scores, operation time, wound healing time, mean hospital stay, incidence of postoperative complications and the curative effect. Results No significant difference was found in view of postoperative pain scores according to visual analogue scale between the 2 groups. The operative time of anal cushion resection was significantly longer than that of the other group, however, its wound healing time, mean hospital stay and incidence of postoperative complications were significantly less. Follow-up study for 3 months after operation found that anal cushion resection had significantly better curative effect than Milligan-Morgan hemorrhoidectomy. Conclusion Anal cushion resection is a safe and practical approach for third- or fourth-degree circular hemorrhoids.

A randomized, controlled trial of diathermy hemorrhoidectomy vs. stapled hemorrhoidectomy in an intended day-care setting with longer-term follow-up.

Cheetham MJ, Cohen CR, Kamm MA, Phillips RK.

St. Mark's Hospital, Northwick Park, Harrow, Middlesex, UK.

Dis Colon Rectum. 2003 Apr; 46(4): 491-7.

PURPOSE: Hemorrhoidectomy is the most effective long-term treatment for hemorrhoids. Although it is possible to perform hemorrhoidectomy as a day case with a high degree of patient satisfaction, patients take an average of 14 days off work after surgery. Stapled hemorrhoidectomy is believed to be less painful than conventional hemorrhoidectomy and should allow an earlier return to work. The aim of this study was to compare both the immediate and the long-term results of stapled hemorrhoidectomy with diathermy hemorrhoidectomy in patients with prolapsing internal hemorrhoids in an intended day-care setting. METHODS: Thirty-one patients were randomly assigned to undergo diathermy hemorrhoidectomy (n = 16) or stapled hemorrhoidectomy performed with a purpose-designed endoluminal stapling device, PPH01T (n = 15). All operations were planned as day or short-stay cases. All patients received lactulose, commenced preoperatively, together with postoperative topical glyceryl trinitrate and oral metronidazole. Patients were assessed by structured interview to assess their symptoms before and after surgery, with an intended follow-up of six months. All patients completed a 10-cm visual analog pain scale daily for the first ten days after surgery. RESULTS: The total pain score (sum of all pain scores) was significantly higher in the diathermy group (50 (range, 9.8-79.9) vs. 19.6 (range, 1.3-89.5), P = 0.03). Patients took a median of 14 (range, 3-21) days off work after diathermy hemorrhoidectomy compared with 10 (range, 3-38) days for the patients undergoing stapled hemorrhoidectomy (P = 0.15). At long-term follow-up, three patients (all in the stapled group) developed new symptoms of fecal urgency and anal pain, and three patients required further surgery to remove symptomatic external hemorrhoids after stapled hemorrhoidectomy. CONCLUSIONS: Although stapled hemorrhoidectomy is less painful in the short term, this does not lead to a significantly earlier return to work, and some patients develop new symptoms at long-term follow-up.

Ambulatory stapled haemorrhoidectomy: a safe and feasible surgical technique.

Law WL, Tung HM, Chu KW, Lee FC.

Department of Surgery, The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong.

Hong Kong Med J. 2003 Apr; 9(2): 103-7.

OBJECTIVE: To compare outcomes following stapled haemorrhoidectomy as an in-patient versus day-surgery procedure. DESIGN: Prospective non-randomised study. SETTING: University affiliated hospitals, Hong Kong. SUBJECTS AND METHODS: Forty-eight consecutive patients who underwent stapled haemorrhoidectomy were included in the study. Twenty-four patients had the procedure in an ambulatory setting and the other 24 were treated as in-patients. The symptoms, operative details, postoperative complications, length of hospital stay, pain scores, analgesic requirements, and patient satisfaction scores were collected. Comparison was made between those patients undergoing ambulatory surgery and those treated as in-patients. RESULTS: There were 25 women and 23 men in the study. The mean age was 46.6 years (standard deviation, 12.1 years). The mean operating time was 29.3 minutes (standard deviation, 9.9 minutes). An incomplete 'doughnut' after stapling was found in one patient. There were no other adverse intra-operative events or complications. Postoperative morbidities occurred in eight patients but none required further surgery. One patient in the day-surgery group could not be discharged because of urinary retention and three required re-admission to hospital because of secondary haemorrhage (n=1) or fever (n=2). There were no differences in the postoperative complications, pain scores, analgesic requirements, and patient satisfaction scores between the two groups. The total mean hospital stay was significantly shorter for those undergoing day-surgery stapled haemorrhoidectomy (0.46 versus 1.9 days, P<0.01). The mean follow-up period was 4.6 months (standard deviation, 4.0 months). All patients reported symptomatic improvement during this time and there was no incidence of faecal incontinence. One patient had a soft stricture, one had a fissure, and two had residual skin tags. All of these problems were conservatively managed, without the need for further surgical procedures. CONCLUSIONS: Stapled haemorrhoidectomy is a safe and effective operation for haemorrhoids. It is a feasible procedure to perform as day-surgery. The hospital stay can be significantly shortened, thus reducing the costs associated with in-patient care.

Randomized trial of rubber band ligation vs. stapled hemorrhoidectomy for prolapsed piles.

Peng BC, Jayne DG, Ho YH.

Department of Colorectal Surgery, Singapore General Hospital, Singapore.

Dis Colon Rectum. 2003 Mar; 46(3): 291-7; discussion 296-7.

PURPOSE: The introduction of stapled hemorrhoidectomy may replace local techniques such as rubber band ligation as a first-line treatment for Grade III and small Grade IV piles. We conducted a randomized trial to determine the role of rubber band ligation in the era of stapled hemorrhoidectomy. METHODS: Fifty-five patients with Grade III or small Grade IV hemorrhoids were randomly allocated to either rubber band ligation or stapled hemorrhoidectomy. Patient demographics and procedure-related details were recorded. Follow-up was at two weeks and two and six months to assess complications, symptom relief, incontinence scores, quality of life, and patient satisfaction. RESULTS: Twenty-five patients were randomly assigned to rubber band ligation and 30 to stapled hemorrhoidectomy. The groups were equally matched for age, gender, grade of piles, continence scores, and quality of life. Stapled hemorrhoidectomy was associated with increased pain and analgesia usage at both 2-week and 2-month follow-up (P < 0.001). Rubber band ligation and stapled hemorrhoidectomy were equally effective in controlling symptomatic prolapse, but rubber band ligation was associated with an increased incidence of recurrent bleeding (P = 0.002). There were 6 procedure-related complications in the stapled hemorrhoidectomy group compared with none in the rubber band ligation group (P = 0.027). There was no difference between the two groups in terms of continence scores, patient satisfaction, or quality of life. CONCLUSION: Stapled hemorrhoidectomy is associated with more pain and minor morbidity than rubber band ligation in the treatment of Grade III and small Grade IV piles. However, for those patients who do not want the risk of further intervention procedures, stapled hemorrhoidectomy offers the better chance of a symptomatic cure.

Stapled and open hemorrhoidectomy: randomized controlled trial of early results.

Palimento D, Picchio M, Attanasio U, Lombardi A, Bambini C, Renda A.

Department of Surgery, Civil Hospital San Rocco, Via Sessa Mignana, 81037 Sessa Aurunca, Caserta, Italy.

World J Surg. 2003 Feb; 27(2): 203-7.

The aim of the study was to compare the early results in 52 patients randomly allocated to undergo either stapled or open hemorrhoidectomy. Seventy-four patients with grade III and IV hemorrhoids were randomly allocated to undergo either stapled (37 patients) or open (37 patients) hemorrhoidectomy. Stapled hemorrhoidectomy was performed with the use of a circular stapling device. Open hemorrhoidectomy was accomplished according to the Milligan-Morgan technique. Postoperative pain was assessed by means of a visual analogue scale (V.A.S.). Recovery evaluation included return to pain-free defecation and normal activities. A 6-month clinical follow-up and a 17.5 (10 to 27)-month median telephone follow-up was obtained in all patients. Operation time for stapled hemorrhoidectomy was shorter (median 25 [range 15 to 49] minutes versus 30 [range 20 to 44] minutes, p = 0.041). Median (range) V.A.S. scores in the stapled group were significantly lower (V.A.S. score after 4 hours: 4 [2 to 6] versus 5 [2 to 8], p = 0.001; V.A.S. score after 24 hours: 3 [1 to 6] versus 5 [3 to 7], p = 0.000; V.A.S. score after first defecation: 5 [3 to 8] versus 7 [3 to 9], p = 0.000). Resumption of pain-free defecation was significantly faster in the stapled group (10 [6 to 14] days vs 12 [9 to 19] days, p = 0.001). At follow-up 4 weeks and 6 months postoperatively the median (range) symptom severity score was similar in both groups (1 [0 to 2] versus 0 [0 to 3], p = 0.150 and 0 [0 to 2] versus 0 [0 to 2], p = 0.731). At long-term follow-up occasional pain was present in 6/37 (16.2) patients in the stapled group and 7/37 (18.9%) in the Milligan-Morgan group (p = 1.000); episodes of bleeding were reported by 8/37 (21.6%) patients in the stapled group and 5/37 (13.5%) patients in the Milligan-Morgan group (p = 0.542). No problems related to continence and defecation were reported in either group. Patients were satisfied with the operation in 33/37 (89.2%) cases in the stapled group and 31/37 (83.8%) cases in the Milligan-Morgan group (p = 0.735). Hemorrhoidectomy with a circular staple device is easy to perform and achieves better results than the Milligan-Morgan technique in terms of postoperative pain and recovery. Comparable results are obtained at long-term follow-up.

Prospective randomized study of bacteraemia in diathermy and stapled haemorrhoidectomy.

Maw A, Concepcion R, Eu KW, Seow-Choen F, Heah SM, Tang CL, Tan AL.

Department of Colorectal Surgery, Singapore General Hospital, Outram Road, Singapore 169608.

Br J Surg. 2003 Feb; 90(2): 222-6.

BACKGROUND: The incidence and consequences of bacteraemia associated with diathermy and stapled haemorrhoidectomy have not been studied previously. METHODS: Two hundred and five healthy patients randomized to stapled haemorrhoidectomy or diathermy haemorrhoidectomy had perioperative blood cultures taken. The clinical sequelae of bacteraemia and complications of surgery were assessed prospectively. RESULTS: Six patients were excluded for protocol violations. Eleven (11 per cent) of 101 patients with stapled and five (5 per cent) of 98 who had diathermy haemorrhoidectomy had positive blood cultures for organisms after haemorrhoidectomy, predominantly anaerobes commonly found within the bacterial flora of the anorectum (P = 0.19). Transient postoperative pyrexia in several patients did not correlate with detected bacteraemia and settled spontaneously without treatment. There were no serious complications from either operative technique, and no clinical consequences from proven bacteraemia. CONCLUSION: Transient bacteraemia may complicate surgical haemorrhoidectomy but has no serious clinical consequences for healthy adults.

Septic complications after treatment of haemorrhoids.

Guy RJ, Seow-Choen F.

Department of Colorectal Surgery, Outram Road, Singapore 169608. richard.guy@pbh-tr.nhs.uk

Br J Surg. 2003 Feb; 90(2): 147-56.

BACKGROUND: Recent reports of serious sepsis following stapled haemorrhoidectomy have raised concerns about the appropriate treatment of haemorrhoidal disease. METHODS: A Medline search was undertaken for reports of sepsis following the commonly practised conservative and surgical treatments of haemorrhoids. RESULTS: Published accounts of significant septic complications after injection sclerotherapy, rubber-band ligation, cryotherapy, open and closed haemorrhoidectomy, and stapled haemorrhoidectomy are discussed. This is supplemented by the authors' own experiences of stapled haemorrhoidectomy. CONCLUSION: Septic complications following both conservative and surgical treatment of haemorrhoids are rare but may be catastrophic. Immunological compromise poses an additional risk for many treatment modalities. The technique of stapled haemorrhoidectomy should be learned diligently to avoid septic complications.

Rectal perforation: a life-threatening complication of stapled hemorrhoidectomy: report of a case.

Wong LY, Jiang JK, Chang SC, Lin JK.

Division of Colon and Rectal Surgery, Department of Surgery, Veterans General Hospital-Taipei, Taiwan, ROC.

Dis Colon Rectum. 2003 Jan; 46(1): 116-7.

Stapled hemorrhoidectomy is considered to be safe and carries advantages. We describe a patient with rectal perforation and fecal peritonitis after stapled hemorrhoidectomy. We suggest that it should be performed by experienced colorectal surgeons who are familiar with the technique and aware of possible complications.

Day-case stapled (circular) vs. diathermy hemorrhoidectomy: a randomized, controlled trial evaluating surgical and functional outcome.

Kairaluoma M, Nuorva K, Kellokumpu I.

Department of Gastroenterological Surgery, Central Hospital of Jyvaskyla, Jyvaskyla, Finland.

Dis Colon Rectum. 2003 Jan; 46(1): 93-9.

PURPOSE: Stapled hemorrhoidectomy may be associated with less pain and faster recovery than conventional hemorrhoidectomy for prolapsing hemorrhoids. Therefore, the outcome of stapled hemorrhoidectomy was compared with that of diathermy hemorrhoidectomy in a randomized, controlled trial. METHODS: Sixty patients with third-degree hemorrhoids were randomly assigned to stapled hemorrhoidectomy (n = 30) or to diathermy hemorrhoidectomy in a day-case setting. Visual analog scale was used for postoperative pain scoring. Surgical and functional outcome was assessed at six weeks and one year after surgery. RESULTS: Operation time was a median of 21 (range, 11-59) minutes in the stapled group. 22 (range, 14-40) minutes in the diathermy group. Day-case surgery was successful in 24 patients (80 percent) in the stapled group vs. 29 patients (97 percent) in the diathermy group. Average pain in the stapled group was significantly lower than in the diathermy group (median, 1.8 (0.1-4.8) vs. 4.3 (1.4-6.2), 95 percent confidence interval difference medians, 1.15-3.85, P = 0.0002, Mann-Whitney U test) as was the average pain expected by the patients (median -2.7 (-0.15-0.8) vs. 0.006 (-4.05-0.5) respectively, 95 percent confidence interval difference medians, 0.5-3.55, P = 0.0018, Mann-Whitney U test). Postoperative morbidity and time off work were not significantly different between the diathermy and stapled groups. Seven treatment failures in the stapled group and one in the diathermy group necessitated other treatments at a later date. Patient satisfaction scores in the stapled and diathermy group were similar. Symptoms attributed to difficult rectal evacuation decreased significantly after surgery. CONCLUSIONS: Stapled hemorrhoidectomy is a significantly less painful operation than diathermy hemorrhoidectomy, but does not seem to offer significant advantages in terms of hospital stay or symptom control in the long term. Hemorrhoidectomy may improve symptoms of difficult rectal evacuation.

Clinical experience of sutureless closed hemorrhoidectomy with LigaSure.

Chung YC, Wu HJ.

Department of Surgery, Hsin-Chu Hospital, Department of Health, Taiwan, Republic of China.

Dis Colon Rectum. 2003 Jan; 46(1): 87-92.

PURPOSE: The purpose of this study was to evaluate the LigaSure vessel sealing system as an alternative to closed hemorrhoidectomy. METHODS: Sixty-one patients with Grade 3 or 4 symptomatic hemorrhoids were prospectively randomly assigned to undergo hemorrhoidectomy with the LigaSure vessel sealing system or hemorrhoidectomy using the conventional Ferguson procedure. We determined the operation time, postoperative pain, amount of time taken off from work, and complications associated with both techniques. RESULTS: Mean operative time for the LigaSure hemorrhoidectomy was 15 +/- 5.4 minutes and for the Ferguson operation, 21.2 +/- 8.2 minutes. The difference was significant (P < 0.01). There was also a significant decrease in pain measurements reported on postoperative Days 1 and 2 (P < 0.05) in the LigaSure group. The incidence of postoperative wound swelling and complications were similar between two groups. There was no difference in the period of time off from work between patient groups. CONCLUSION: This study confirms that LigaSure system can achieve a radical ablation of hemorrhoids, reduce operative time, and result in less postoperative pain on postoperative Days 1 and 2.