Low hemorrhoidopexy staple line does not improve results and increases risk for incontinence

Abstract

The ability of stapled hemorrhoidopexy (SH) to cure hemorrhoidal symptoms appears to depend on patient characteristics and operative technique. We assessed the association between outcome of SH and patients' characteristics and procedure parameters (associated procedure, suture line height, doughnut size, presence of malpighian tissue or smooth muscle in specimen). A total of 68 consecutive patients (56 males) were prospectively operated by 3 different surgeons. Hemorrhoids were grade II (6%), grade III (76%) or grade IV (18%). At a mean 32-week follow-up (range, 9-77), symptoms had resolved in 77% of patients, independently of any operative or clinical parameter. New onset anal incontinence occurred in 11 men (17%): all had urgency, with flatus and liquid stool incontinence in two, and flatus incontinence and mucus soiling in one. Univariate analysis revealed that persistent incontinence was associated with a staple line <6.5 mm from the dentate line, doughnut height <22 mm, and congestive external hemorrhoids; it was also operator dependent (p<0.05). At the 4-week follow-up, 19% of patients had persisting symptoms but only 8% had a demonstrable mucosal prolapse. Although the success rate of SH may not be influenced by technical variations, risk for moderate incontinence is elevated when the stapled line is low.