A prospective evaluation of the introduction of circumferential stapled anoplasty in the management of haemorrhoids and mucosal prolapse

Abstract

Prolapsing haemorrhoids and rectal mucosal prolapse are commonly seen in colorectal practice. Conventional treatment of haemorrhoids and mucosal prolapse by variations of the ligation-excision technique can achieve good results in expert hands. However, post-operative complications are well recognized and may result in prolonged in-patient stay. The aim of this study was to evaluate prospectively a submucosal resection anoplasty technique using a circular stapling device in a consecutive series of patients requiring surgery for haemorrhoids or mucosal prolapse, and to assess the suitability of this technique for day case surgery. Forty-three consecutive circumferential stapled anoplasty procedures were carried out in 41 patients (24 males, median age 50 years; range 29-84 years). Indications for surgery were grade III (25 cases (58%)) and IV (15 cases (35%)) haemorrhoids or mucosal prolapse (three cases (7%)). The predominant symptoms included bleeding in 22 (51%) and persistent mucous discharge in nine (21%). Nineteen patients (46%) had previously undergone treatment for haemorrhoids. Patients were eligible following appropriate investigation. The majority of cases were carried out in the prone jack knife position (n=41 (95%)) and under general anaesthetic (n=40 (93%)). A circular closed excision staple gun was used in all cases. The median distance from the dentate line to the insertion of the pursestring suture was 50 mm and at completion of stapling 20 mm. Excision doughnuts were complete in all cases. Of the 29 (70%) patients eligible for day case surgery 21 (72%) were discharged on the day of surgery. The commonest cause for delayed discharge in the group eligible for day case surgery was pain requiring intramuscular opiate analgesia. The median visual analogue pain score (0-10) on discharge was 1 (interquartile range (IQR) 0-2). One patient was readmitted on the third post-operative day with severe anal pain and spasm secondary to a staple line infection. Thirty-five (85%) patients had been followed up at 8 weeks and 18 (43%) at 6 months. Thirty (86%) of the patients seen at 8 weeks were very satisfied with the results of the procedure. Time to return to normal activity was median 4 (IQR 2-7.5) days. Two patients complained of slight transient alteration in bowel habit and proctoscopic examination revealed minor stenosis of the staple line, treated with dilation in clinic. Two patients (both with initially large 4th degree haemorrhoids) had small residual haemor- rhoids which required repeat stapled anoplasty. Transanal stapled anoplasty achieves good functional results and patient satisfaction in the surgical management of haemorrhoids and mucosal prolapse. With careful surgical technique, strict attention to haemostasis and adequate post-operative analgesia this procedure can feasibly be carried out on a day case basis. Minor complications are similar to those of conventional surgery. Though longer-term follow up is required, no major complications were observed in this consecutive series.