TY - JOUR
AU - Eu, K-W
AB - Abstract Background Stapled haemorrhoidectomy has been routinely performed in the Department of Colorectal Surgery, Singapore General Hospital since 1999. Methods A retrospective review was undertaken of all patients who underwent stapled haemorrhoidectomy between October 1999 and May 2004. The outcomes studied were patient profiles, priority of operation, indications for surgery, length of operation, postoperative complications and recurrences. Results A total of 3711 patients (51·1 per cent women) had the surgery. The median patient age was 50 (range 18–88) years. The main indications were bleeding (80·7 per cent), haemorrhoidal prolapse (59·6 per cent) and thrombosis (3·9 per cent). The median duration of operation was 15 (range 5–45) min. Minor complications occurred in 12·3 per cent of patients: acute retention of urine (4·9 per cent), bleeding (4·3 per cent), significant postoperative pain requiring admission (1·6 per cent), anorectal stricture (1·4 per cent), perianal haematoma (0·05 per cent) and significant residual skin tags (0·05 per cent). One patient developed a perianal abscess after stapled haemorrhoidectomy. Anastomotic dehiscence occurred in three patients (0·08 per cent). Twelve (0·3 per cent) patients had a recurrence at a median of 16 (range 5–45) months. Conclusion Considerable experience of stapled haemorrhoidectomy confirms it as a safe and effective procedure. Introduction The use of stapled haemorrhoidectomy for the treatment of third and fourth degree prolapse was first introduced in Singapore in late 1999. Since then, the Department of Colorectal Surgery, Singapore General Hospital, has performed this procedure more than 3700 times and now does so routinely in an ambulatory setting1. The aim of this paper was to review retrospectively the effectiveness and efficiency of this procedure. Patients and methods Data from a prospectively maintained database on patients who had undergone stapled haemorrhoidectomy between October 1999 and July 2004 were retrospectively analysed. Case records were also retrieved and analysed. The main outcomes studied were: patient profiles, priority of operation, indications for surgery, length of operation, postoperative complications and recurrences. Postoperative complications were defined as acute retention of urine, bleeding, pain, anorectal stricture, perianal abscess and anastomotic dehiscence. Stapled haemorrhoidectomy was performed using a modification of the Longo technique1, with a PPH01® Stapler (Ethicon Endo-Surgery, Cincinnati, Ohio, USA). A circumferential purse-string of 2/0 polypropylene was placed 2–3 cm proximal to the dentate line. Haemostasis along the stapler line was then ensured using diathermy and suture. All patients were given a follow-up appointment in the outpatient clinic after surgery. The first appointment could vary from 2 to 4 weeks, depending on the preferences of the individual consultants. Almost all patients were seen again for one or two visits. Patients were then discharged if there were no short-term complications and asked to return to clinic if problems occurred in future. Results Between October 1999 and May 2004, 3711 patients underwent stapled haemorrhoidectomy (Fig. 1). The median age of the patients was 50 (range 18–88) years. Some 51·1 per cent were women. The main indications for surgery were bleeding (80·7 per cent), third or fourth degree haemorrhoidal prolapse (59·6 per cent) or haemorrhoid thrombosis (3·9 per cent). Surgery was elective in 96·1 per cent of the procedures and acute in 3·9 per cent. The median duration of operation was 15 (range 5–45) min. Fig. 1 Open in new tabDownload slide Number of stapled haemorrhoidectomies performed between October 1999 and May 2004 Complications One hundred and eighty-three (4·9 per cent) patients were admitted for acute retention of urine; 101 required urinary catheterization (2·7 per cent), after failing a trial of conservative treatment. Only seven patients required referral to a urologist for further evaluation. At subsequent follow-up in the outpatient clinic, none of the patients was noted to require permanent catheterization. Postoperative bleeding occurred in 160 patients (4·3 per cent): 52 had bleeding on the same day of the surgery, 127 within the first week and 154 within the first 2 weeks (Fig. 2). Bleeding tended to occur either immediately after surgery or between the fourth and tenth day after surgery. Twenty-seven patients required blood transfusion. In 81 patients, the bleeding stopped without intervention. In 66 patients, proctoscopy in the ward identified the bleeding point and submucosal adrenaline injections were attempted2, being successful in 62 patients. The other four patients underwent examination under anaesthesia and had surgical haemostasis. Overall, 16 patients (0·43 per cent) required a second anaesthesia for surgical haemostasis. Fig. 2 Open in new tabDownload slide Occurrence of postoperative bleeding after stapled haemorrhoidectomy Significant postoperative pain requiring admission occurred in 57 patients (1·6 per cent). Thirty-six patients were readmitted immediately after surgery. The median duration of hospital stay was 1 (range 1–5) day. Twenty-one patients were readmitted a median of 6 (range 1–20) days following surgery. These 21 patients stayed for a median of 2 (range 1–6) days. All patients were treated conservatively with analgesia. No patient complained of persistent pain after stapled haemorrhoidectomy. The incidence of anorectal stricture requiring intervention was 1·4 per cent (52 of 3711 patients). Most of these strictures occurred in the early postoperative period (Fig. 3). Late stricture (i.e. later than 3 months after operation) occurred in nine patients at a median time of 9 (range 5–25) months. None of the patients developed recurrent stricture after stricturoplasty or anal dilatation. However, one patient developed anastomotic dehiscence after stricturoplasty that required repair and defunctioning colostomy. This major complication occurred in three patients (0·08 per cent). All required repair and temporary defunctioning colostomy. One patient developed retroperitoneal sepsis in the postoperative period3, the second dehiscence was recognized immediately after the firing of the stapler and the last occurred after stricturoplasty. One patient had stapled haemorrhoidectomy and treatment of low fistula in ano at the same operation4. This patient later developed a large anterior horseshoe abscess that required further surgery for incision and drainage. Fig. 3 Open in new tabDownload slide Postoperative anorectal stricture after stapled haemorrhoidectomy Two patients presented with severe pain secondary to perianal thrombosis after stapled haemorrhoidectomy, on the seventh and tenth day after surgery. Evacuation of haematoma was performed for both patients. Three patients complained of significant residual perianal skin tags after stapled haemorrhoidectomy. Excision of these skin tags was undertaken for these patients under general anaesthesia. Recurrence occurred in 12 patients (0·3 per cent). The median time to recurrence was 16 (range 5–45) months. Only one patient presented with recurrent bleeding and was successfully treated with conservative measures. The other 11 patients had significant haemorrhoidal prolapse and had to undergo further haemorrhoidectomy. Nine open haemorrhoidectomy operations for solitary prolapse and two repeat stapled haemorrhoidectomy operations for circumferential prolapse were performed. Discussion The use of stapled haemorrhoidectomy for the treatment of symptomatic haemorrhoids has become increasing popular over the past few years. To date, 18 randomized controlled trials have been conducted5–22. The results of these trials show a clear advantage of stapled haemorrhoidectomy in terms of less pain, faster recovery and resumption of activities of daily living23. The complication rate of this new procedure is also comparable to that of conventional methods. Important advantages of stapled haemorrhoidectomy are the reduction in postoperative pain, shorter hospital stay and earlier return to daily activities and work. However, immediate postoperative pain can be quite significant in some patients. In this series, a small number of patients had pain immediately after surgery that required hospital admission. There are several explanations for this postoperative pain24. Using a circular stapler results in the reduction of vascular supply to the haemorrhoids, circumferential excision of redundant rectal mucosa, reduction and fixation of prolapsed haemorrhoidal tissue, and preservation of the anal transitional zone. In some patients, the pain may be due to thrombosis of the haemorrhoidal tissues left behind after the procedure. Where the prolapse has a large circumference, the tendency is to place the stapled line too close to the anal verge in an attempt to incorporate more redundant rectal and haemorrhoidal tissues into the stapler. However, this may result in the partial excision of the sensitive anoderm, with the effect of significant postoperative pain. Lastly, inappropriate placement of the purse-string may result in incorporation of rectal muscle and nerves, with resulting pain after surgery. Several cases of persistent pelvic pain after stapled haemorrhoidectomy were reported with early experience of the procedure25. However, none of the patients in this series experienced persistent pain. Bleeding after haemorrhoidectomy is a very common complication. In conventional haemorrhoidectomy, bleeding may arise from the vascular pedicle or from the edges of the wound. However, in the stapled method, bleeding occurs at the stapled line. When recognized during surgery, haemostasis can be achieved by under-running the bleeding point. In the postoperative setting, bleeding can be managed successfully with a submucosal injection of adrenaline under proctoscopy. Failure with this method is due to difficulty in identifying the bleeding point when the rectal mucosa and anastomosis are stretched under proctoscopy. Some patients were not able to tolerate proctoscopy without significant discomfort. In these cases, haemostasis is best achieved under anaesthesia. With the use of the newer PPH03®, which has a closed staple height of 0·75 mm, postoperative bleeding may be reduced owing to an increase in compression on rectal tissue and blood vessels. Acute retention of urine is also common after haemorrhoidectomy. This is usually because of a combination of anaesthesia, postoperative pain and anxiety. After a trial of conservative measures, most of these patients will require temporary urinary catheterization. Usually the catheter can be successfully removed after 1 day. A few patients required a longer period of catheterization. For women, rectovaginal fistula formation is possible after stapled haemorrhoidectomy26. This can be avoided by assessing the thickness of the rectovaginal septum before inserting the purse-string. Care should be taken not to place too deep a suture anteriorly during placement of the purse-string. The vagina must be examined before firing the stapler. Formation of anorectal stricture is a known complication after stapled haemorrhoidectomy, with a reported incidence of about 5 per cent23. It has been postulated that the occurrence of stricture is due to the placement of the purse-string, and thus the anastomosis, below the accepted 4 cm from the anal verge. However, in this series, stricture occurred regardless of the height of the anastomosis with respect to the anal verge. Most stricture formation occurred very early in the postoperative period. Digital dilatation can be easily performed when patients are reviewed early after surgery, usually about 2 weeks. At that time, the fibrous tissues forming the stricture are soft and easily disrupted. With this, only a small percentage of patients developed symptomatic stricture that required surgical intervention. The majority of these patients developed significant stricture within the first few months after surgery. Simple stricturoplasty or anal dilatation is all that is necessary for anorectal stricture formation after stapled haemorrhoidectomy. The most serious complication of stapled haemorrhoidectomy is anastomotic dehiscence27. Though rare, early diagnosis it is important, as the resulting sepsis can be life-threatening. Management should follow that of anastomotic dehiscence with laparotomy, peritoneal lavage, anastomotic repair and defunctioning colostomy. Stapled haemorrhoidectomy is a ‘radical’ procedure that aims to remove all the haemorrhoidal vasculature, yet recurrence can occur. In the current series, this may be because of incomplete transection of the haemorrhoidal vessels, poor fixation of the anal cushion to the anorectal musculature or even neovascularization. The authors recommend conventional surgery for recurrence, as these patients usually present with single haemorrhoidal prolapse. In selected patients, repeated stapled haemorrhoidectomy may be effective. This study, the largest single centre experience published to date, has shown that stapled haemorrhoidectomy is safe and effective for the treatment of haemorrhoids that require surgery. References 1 Guy RJ , Ng CE, Eu KW. Stapled anoplasty for haemorrhoids; a comparison of ambulatory vs. in-patient procedures . Colorectal Dis 2003 ; 5 : 29 – 32 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Nyam DC , Seow-Choen F, Ho YH. Submucosal adrenaline injection for posthemorrhoidectomy hemorrhage . Dis Colon Rectum 1995 ; 38 : 776 – 777 . Google Scholar Crossref Search ADS PubMed WorldCat 3 Maw A , Eu KW, Seow-Choen F. Retroperitoneal sepsis complicating stapled hemorrhoidectomy: report of a case and review of the literature . Dis Colon Rectum 2002 ; 45 : 826 – 828 . Google Scholar Crossref Search ADS PubMed WorldCat 4 Ng KH , Eu KW, Ooi BS, Heah SM, Tang CL, Seow-Choen F. Stapled hemorrhoidopexy for prolapsed piles performed with concurrent perianal conditions . Tech Coloproctol 2003 ; 7 : 214 – 215 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 5 Ho YH , Seow-Choen F, Tsang C, Eu KW. Randomized trial assessing anal sphincter injuries after stapled haemorrhoidectomy . Br J Surg 2001 ; 88 : 1449 – 1455 . Google Scholar Crossref Search ADS PubMed WorldCat 6 Peng BC , Jayne DG, Ho YH. Randomized trial of rubber band ligation versus stapled hemorrhoidectomy for prolapsed piles . Dis Colon Rectum 2003 ; 46 : 291 – 297 . Google Scholar Crossref Search ADS PubMed WorldCat 7 Brown SR , Ballan K, Ho E, Ho YH, Seow-Choen F. Stapled mucosectomy for acute thrombosed circumferentially prolapsed piles: a prospective randomized comparison with conventional haemorrhoidectomy . Colorectal Dis 2001 ; 3 : 175 – 178 . Google Scholar Crossref Search ADS PubMed WorldCat 8 Mehigan BJ , Monson JR, Hartley JE. Stapling procedure for haemorrhoids versus Milligan–Morgan haemorrhoidectomy: randomised controlled trial . Lancet 2000 ; 355 : 782 – 785 . Google Scholar Crossref Search ADS PubMed WorldCat 9 Rowsell M , Bello M, Hemingway DM. Circumferential mucosectomy (stapled haemorrhoidectomy) versus conventional haemorrhoidectomy: randomised controlled trial . Lancet 2000 ; 355 : 779 – 781 . Google Scholar Crossref Search ADS PubMed WorldCat 10 Ortiz H , Marzo J, Armendariz P. Randomized clinical trial of stapled haemorrhoidopexy versus conventional diathermy haemorrhoidectomy . Br J Surg 2002 ; 89 : 1376 – 1381 . Google Scholar Crossref Search ADS PubMed WorldCat 11 Khalil KH , O'Bichere A, Sellu D. Randomized clinical trial of sutured versus stapled closed haemorrhoidectomy . Br J Surg 2000 ; 87 : 1352 – 1355 . Google Scholar Crossref Search ADS PubMed WorldCat 12 Hetzer FH , Demartines N, Handschin AE, Clavien PA. Stapled versus excision hemorrhoidectomy: long-term results of a prospective randomized trial . Arch Surg 2002 ; 137 : 337 – 340 . Google Scholar Crossref Search ADS PubMed WorldCat 13 Shalaby R , Desoky A. Randomized clinical trial of stapled versus Milligan-Morgan haemorrhoidectomy . Br J Surg 2001 ; 88 : 1049 – 1053 . Google Scholar Crossref Search ADS PubMed WorldCat 14 Ganio E , Altomare DF, Gabrielli F, Milito G, Canuti S. Prospective randomized multicentre trial comparing stapled with open haemorrhoidectomy . Br J Surg 2001 ; 88 : 669 – 674 . Google Scholar Crossref Search ADS PubMed WorldCat 15 Boccasanta P , Capretti PG, Venturi M, Cioffi U, De Simone M, Salamina G et al. Randomized controlled trial between stapled circumferential mucosectomy and conventional circular hemorrhoidectomy in advanced hemorrhoids with external mucosal prolapse . Am J Surg 2001 ; 182 : 64 – 68 . Google Scholar Crossref Search ADS PubMed WorldCat 16 Correa-Rovelo JM , Tellez O, Obregon L, Miranda-Gomez A, Moran S. Stapled rectal mucosectomy vs. closed hemorrhoidectomy: a randomized, clinical trial . Dis Colon Rectum 2002 ; 45 : 1367 – 1374 . Google Scholar Crossref Search ADS PubMed WorldCat 17 Pavlidis T , Papaziogas B, Souparis A, Patsas A, Koutelidakis I, Papaziogas T. Modern stapled Longo procedure vs. conventional Milligan-Morgan hemorrhoidectomy: a randomized controlled trial . Int J Colorectal Dis 2002 ; 17 : 50 – 53 . Google Scholar Crossref Search ADS PubMed WorldCat 18 Cheetham MJ , Cohen CR, Kamm MA, Phillips RK. A randomized, controlled trial of diathermy hemorrhoidectomy vs. stapled hemorrhoidectomy in an intended day-care setting with longer-term follow-up . Dis Colon Rectum 2003 ; 46 : 491 – 497 . Google Scholar Crossref Search ADS PubMed WorldCat 19 Kairaluoma M , Nuorva K, Kellokumpu I. Day-case stapled (circular) vs. diathermy hemorrhoidectomy: a randomized, controlled trial evaluating surgical and functional outcome . Dis Colon Rectum 2003 ; 46 : 93 – 99 . Google Scholar Crossref Search ADS PubMed WorldCat 20 Palimento D , Picchio M, Attanasio U, Lombardi A, Bambini C, Renda A. Stapled and open hemorrhoidectomy: randomized controlled trial of early results . World J Surg 2003 ; 27 : 203 – 207 . Google Scholar Crossref Search ADS PubMed WorldCat 21 Wilson MS , Pope V, Doran HE, Fearn SJ, Brough WA. Objective comparison of stapled anopexy and open hemorrhoidectomy: a randomized, controlled trial . Dis Colon Rectum 2002 ; 45 : 1437 – 1444 . Google Scholar Crossref Search ADS PubMed WorldCat 22 Racalbuto A , Aliotta I, Corsaro G, Lanteri R, Di Cataldo A, Licata A. Hemorrhoidal stapler prolapsectomy vs. Milligan-Morgan hemorrhoidectomy: a long-term randomized trial . Int J Colorectal Dis 2004 ; 19 : 239 – 244 . Google Scholar Crossref Search ADS PubMed WorldCat 23 Sutherland LM , Burchard AK, Matsuda K, Sweeney JL, Bokey EL, Childs PA et al. A systematic review of stapled hemorrhoidectomy . Arch Surg 2002 ; 137 : 1395 – 1406 . Google Scholar Crossref Search ADS PubMed WorldCat 24 Seow-Choen F . Stapled haemorrhoidectomy: pain or gain . Br J Surg 2001 ; 88 : 1 – 3 . Google Scholar Crossref Search ADS PubMed WorldCat 25 Cheetham MJ , Mortensen NJ, Nystrom PO, Kamm MA, Phillips RK. Persistent pain and faecal urgency after stapled haemorrhoidectomy . Lancet 2000 ; 356 : 730 – 733 . Google Scholar Crossref Search ADS PubMed WorldCat 26 McDonald PJ , Bona R, Cohen CR. Rectovaginal fistula after stapled haemorrhoidopexy . Colorectal Dis 2004 ; 6 : 64 – 65 . Google Scholar Crossref Search ADS PubMed WorldCat 27 Molloy RG , Kingsmore D. Life threatening pelvic sepsis after stapled haemorrhoidectomy . Lancet 2000 ; 355 : 810 . Google Scholar Crossref Search ADS PubMed WorldCat Author notes Presented to a meeting of the European Association of Coloproctology, Geneva, Switzerland, September 2004 Copyright © 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) Copyright © 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
TI - Experience of 3711 stapled haemorrhoidectomy operations
JO - British Journal of Surgery
DO - 10.1002/bjs.5214
DA - 2006-01-23
UR - https://www.deepdyve.com/lp/oxford-university-press/experience-of-3711-stapled-haemorrhoidectomy-operations-hL00Oq0sr0
SP - 226
EP - 230
VL - 93
IS - 2
DP - DeepDyve
ER -