Fourth-degree Hemorrhoids Research Articles

An evaluation of Milligan-Morgan and Ferguson procedures for haemorrhoidectomy at Liaquat University Hospital Jamshoro, Hyderabad, Pakistan.

Objective: o compare the outcome of Milligan-Morgan (MMH) and Ferguson (FH) techniques for haemorrhoidectomy with regard to postoperative pain, control of bleeding, early mobilization of patients and wound healing. Methodology: In this prospective, randomized clinical study conducted between January 2005 to December 2008, 213 patients with late 2nd degree; third or fourth degree hemorrhoids were assigned to two groups. One hundred ten patients in group A were operated by an open method and 103 patients in group B were operated by closed method. Results: Age ranged from 22-70 years with mean age of 45.5 years. Peak incidence was between 41-50 years. Out of 213 patients, 170 (79.81%) were male and 43 (20.18%) were females. The mean ± SD operating time was significantly more in group B (31.3±4.8 min) than group A (25.2±5.6). The duration of hospitalization and duration off from work was more in group A than the group B. Wound healing was quicker in group B than the group A. Post operative pain scores were significantly low in the Group A than Group B during first 24 hours and at first bowel movements. Reactionary hemorrhage occurred in 4 (3.63%) patients of group A, no patient in group B developed this complication. Retention of urine was seen in 13 (11.81%) patients in group A and 4 (3.88%) in group B. No patient in group A developed anal stenosis, while 3 (2.91%) patients in group B developed anal stenosis. Wound infection was one (0.9%) in group A and two (1.9%) in group B. Two (3.63%) patients in group A came with recurrent hemorrhoids and in group B, only one (0.97%) patient reported recurrence. Conclusions: The closed technique is more beneficial with respect to postoperative pain, control of bleeding, early mobilization of patients and wound healing.

Day case stapled anopexy for the treatment of haemorrhoids and rectal mucosal prolapse

Stapled anopexy (SA) gives better early postoperative results than classical haemorrhoidectomy. The aim of this study is to demonstrate that SA is a safe and effective procedure for the treatment of haemorrhoids and rectal mucose prolapse in a day-case surgery programme. From January 2000 to December 2008, 297 SA procedures were performed; 230 (77.4%) were performed in the Day Surgery Unit (DSU). Third- and fourth-degree haemorrhoids, second-degree haemorrhoids with no response to conservative treatment and several cases of rectal prolapse were included. The mean age of the patients in the series was 48.1 years (range 21-85). Preoperative preparation included phosphate enemas and antibiotic prophylaxis. Patients were operated on mainly under spinal anaesthesia. Day-case rate, postoperative pain (measured by a visual analogic scale, 1-10), admissions, re-admissions, early postoperative situation and recurrence were evaluated in the study. The overall DSU rate was 78%, with a progressive increase from 46% to 99% in 2008. One hundred and eighty-five patients (80%) had pain scores under 2; no patient had a pain score over 7. Eighteen (8%) patients required admission on the day of surgery. Late admission was needed for 3 (3%) patients. Thirty-three patients reported their situation as excellent, 174 as good, 20 as acceptable and three as bad when they answered a phone questionnaire 24 h after surgery. Overall, 20 (9%) patients had recurrence of symptoms. SA is a safe and effective procedure for prolapsing haemorrhoids in the day case setting. The recurrence rate is higher than that observed in classical haemorrhoidectomy. Most patients can be managed as day-cases.

Excisional hemorrhoidal surgery and its effect on anal continence

To investigate the role of anal cushions in hemorrhoidectomy and its effect on anal continence of the patients. Seventy-six consecutive patients (33 men and 43 women) with a mean age of 44 years were included. They underwent Milligan-Morgan hemorrhoidectomy because of symptomatic third- and fourth-degree hemorrhoids and failure in conservative treatment for years. Wexner score was recorded and liquid continence test was performed for each patient before and two months after operation using the techniques described in our previous work. The speed-constant rectal lavage apparatus was prepared in our laboratory. The device could output a pulsed and speed-constant saline stream with a high pressure, which is capable of overcoming any rectal resistance change. The patients were divided into three groups, group A (< 900 mL), group B (900-1200 mL) and group C (> 1200 mL) according to the results of the preoperative liquid continence test. All the patients completed the study. The average number of hemorrhoidal masses excised was 2.4. Most patients presented with hemorrhoidal symptoms for more than one year, including a mean duration of incontinence of 5.2 years. The most common symptoms before surgery were anal bleeding (n = 55), prolapsed lesion (n = 34), anal pain (n = 12) and constipation (n = 17). There were grade III hemorrhoids in 39 (51.3%) patients, and grade IV in 37 (48.7%) patients according to Goligher classification. Five patients had experienced hemorrhoid surgery at least once. Compared with postoperative results, the retained volume in the preoperative liquid continence test was higher in 40 patients, lower in 27 patients, and similar in the other 9 patients. The overall preoperative retained volume in the liquid continence test was 1130.61 ± 78.35 mL, and postoperative volume was slightly decreased (991.27 ± 42.77 mL), but there was no significant difference (P = 0.057). Difference was significant in the test value before and after hemorrhoidectomy in group A (858.24 ± 32.01 mL vs 574.18 ± 60.28 mL, P = 0.011), but no obvious difference was noted in group B or group C. There was no significant difference in Wexner score before and after operation (1.68 ± 0.13 vs 2.10 ± 0.17, P = 0.064). By further stratified analysis, there was significant difference before and 2 months after operation in group A (2.71 ± 0.30 vs 3.58 ± 0.40, P = 0.003). In contrast, there were no significant differences in group B or group C (1.89 ± 0.15 vs 2.11 ± 0.19, P = 0.179; 0.98 ± 0.11 vs 1.34 ± 0.19, P = 0.123). There is no difference in the continence status of patients before and after Milligan-Morgan hemorrhoidectomy. However, patients with preoperative compromised continence may have further deterioration of their continence, hence Milligan-Morgan hemorrhoidectomy should be avoided in such patients.

ALTA Injection Sclerosing Therapy: Non-Excisional Treatment of Internal Hemorrhoids

Aluminum potassium sulfate and tannic acid (ALTA) is a new sclerosing therapy for internal hemorrhoids. This injection therapy is a four-step direct injection sclerosing procedure intended to shrink and harden internal hemorrhoids to eliminate hemorrhoidal prolapse and bleeding. The aim of this study was to assess the short term efficacy of this treatment. The procedure was conducted using a four-step injection process under perianal local anesthesia. The entry point for the four-step injection of ALTA is the submucosa of the superior pole, the submucosa in the central part, the mucous lamina propria in the central part and the submucosa at the inferior pole of hemorrhoid. From January 2009 to March 2010, we performed the ALTA sclerosing therapy on 28 patients (14 men and 14 women; mean age, 64.6 years), including 5 second-degree, 16 third-degree and 7 fourth-degree hemorrhoids. There were 6 postoperative complications (2 cases of low grade fever, 2 anal pains, 1 necrosis at injection site and 1 perianal dermatitis). All symptoms of prolapse or bleeding disappeared after 29 postoperative days. There were 3 recurrent cases (10.7%). ALTA sclerosing therapy is a useful and less invasive treatment for internal hemorrhoids.

Stapled and conventional Milligan–Morgan haemorrhoidectomy: different solutions for different targets

Haemorrhoidal disease is one of the most common anorectal disorders. The aim of this study is to compare the results, over the last 10 years, of stapled haemorrhoidopexy (SH) with those of standard Milligan-Morgan haemorrhoidectomy (M&M). Furthermore, we discuss the proper indications for each technique in terms of the lowest rate of complications and long-term results. Three hundred forty-three patients with different degrees of symptomatic haemorrhoids underwent SH or M&M from January 2005 to December 2007. Patients were divided into two groups, age and sex matched. The administration of painkillers drugs, antibiotics and laxatives, complication symptoms and hospital stay in all the patients were recorded after surgical treatment. The mean operative time was shorter in the stapled group compared to that in the open group (31 min versus 40 min). Postoperative pain, hospital stay and return to full activity were shorter in the stapled group. There was a significant difference in the wound healing time between the two groups. We noticed a higher rate of recurrence in patients treated with stapled haemorrhoidectomy for fourth-degree haemorrhoids. According to our experience, the Longo technique is indicated for the treatment of haemorrhoids of second- and third degree. In the latter grades of prolapse, the Milligan-Morgan haemorrhoidectomy can also be applied with good outcomes. We believe that, in case of irreducible prolapse, the M&M is to be preferred. However, operative management varies according to surgeon's interest and is tailored to meet the individual patient's need.

Stapled hemorrhoidopexy, an innovative surgical procedure for hemorrhoidal prolapse: cost-utility analysis

AimTo undertake full economic evaluation of stapled hemorrhoidopexy (PPH) to establish its cost-effectiveness and investigate whether PPH can become cost-saving compared to conventional excisional hemorrhoidectomy (CH).MethodsA cost–utility analysis in hospital and health care system (UK) was undertaken using a probabilistic, cohort-based decision tree to compare the use of PPH with CH. Sensitivity analyses allowed showing outcomes in regard to the variations in clinical practice of PPH procedure. The participants were patients undergoing initial surgical treatment of third and fourth degree hemorrhoids within a 1-year time-horizon. Data on clinical effectiveness were obtained from a systematic review of the literature. Main outcome measures were the cost per procedure at the hospital level, total direct costs from the health care system perspective, quality adjusted life years (QALY) gained and incremental cost per QALY gained.ResultsA decrease in operating theater time and hospital stay associated with PPH led to a cost saving compared to CH of GBP 27 (US $43.11, €30.50) per procedure at the hospital level and to an incremental cost of GBP 33 (US $52.68, €37.29) after one year from the societal perspective. Calculation of QALYs induced an incremental QALY of 0.0076 and showed an incremental cost-effective ratio (ICER) of GBP 4316 (US $6890.47, €4878.37). Taking into consideration recent literature on clinical outcomes, PPH becomes cost saving compared to CH for the health care system.ConclusionsPPH is a cost-effective procedure with an ICER of GBP 4136 and it seems that an innovative surgical procedure could be cost saving in routine clinical practice.

Local hemostatic effect of cellulose tampons (Tampax) after stapled hemorrhoidopexy

Dear Editor: Longo’s hemorrhoidopexy was introduced in 1998 as a valid alternative to the traditional Milligan and Morgan’s excision. During this new procedure, the surgeons remove a redundant portion of rectal mucosa with a circular stapler, lift the prolapsed hemorrhoidal tissue and cut off the end branches of the superior hemorrhoidal artery. Bleeding is the most frequent complication and its incidence varies from 0.6% to 10%. Blood loss along the staple line is frequently arterious, sometimes venous or appears as a submucosal hematoma. Usually, the hemorrage occurs during or immediately after the operation, sometimes after the first 24–48 postoperative hours, but there is also evidence of late bleeding after 2–6 weeks or even 2– 18 months. Nevertheless, the incidence of both early and late blood loss is actually underestimated because often it is negligible or it is not made known. A pression exerted by a Foley catheter or gauze pads, the local injection of epinephrine and additional surgical sutures are the usual treatments to stop the bleeding complications. Some patients may require blood transfusions. Retrospectively, in a series of 210 patients after stapled hemorrhoidectomy without tampons, we observed an early postoperative bleeding in 1.5% (unpublished data), most of them attributable to the learning curve. The aim of the study we report hereinafter is twofold: to evaluate the local hemostatic effect of a standard rectal tampon left in situ for 24 h after stapled hemorrhoidectomy and to analyse the composition of the fluids absorbed after varying the composition of the tampon surface. Ninety patients (51 males, 39 females, 25–78 years) affected by third and fourth degree hemorrhoids who underwent hemorrhoidopexy according to the Longo’s technique utilizing PPH2 staplers (Ethycon Endo-Surgery, Cincinnati OH, USA) were perspectively studied in three general hospitals. Patients were randomized with a dynamic method: minimization of frequency allocation in groups I– III of 0.5 for patients from 01 to 60; frequency allocation in groups II–III of 0.5 for patients from 61 to 90. The recruitment was made with the first 90 patients presented themselves since January 2009 to the achievement of the 90th unit (February 2010) according to the guidelines of reference for the reporting of clinical trials of consort statement. During surgery, all the patients received additional sutures to complete the hemostasis and were subjected to a 24-h postoperative hemostatic tamponage of the rectal stapled line. A standard cellulose-pressed tampon (Tampax Super, Fater SpA, Pescara, Italy), 6 cm in length and 1.5 cm in diameter, dry weight 3,35 g, was used in 32 A. Battista :A. Novi Division of Emergency Surgery, San Giovanni di Dio e Ruggi D’Aragona Universitary Hospital, Salerno, Italy

Stapled haemorrhoidopexy transiently decreases rectal compliance and sensitivity

Stapled haemorrhoidopexy may damage the anorectal musculature and its sensorimotor function. Most studies have not used a barostat for the measurement of compliance. This study aimed to investigate the effect of stapled haemorrhoidopexy on rectal compliance and sensitivity. After Ethical Committee approval, we studied 10 male patients (mean age 33.8 years) with third- or fourth-degree haemorrhoids. Rectal compliance and sensitivity were measured with a 600-ml bag and an electronic barostat. Volunteers were submitted to two consecutive rectal distension protocols, including continuous distension at 2, 4 and 6 months after stapled haemorrhoidopexy. Intraluminal volume and pressure were recorded, including the first rectal sensation, desire to defecate and onset of rectal pain. Another group of 10 male control patients (mean age 24.9 years) with pilonidal sinus and no haemorrhoids was also included in the study. Two months after stapled haemorrhoidopexy, rectal compliance decreased (7.1 ± 0.2 vs 5.3 ± 0.1, 6.4 ± 0.1 vs 5.1 ± 0.1 and 5.6 ± 0.2 vs 4.7 ± 0.1 ml/mmHg for first rectal sensation, desire to defecate and rectal pain, respectively; P < 0.05). The sensitivity threshold volume did not change for the first sensation but decreased significantly for the desier to defecate and pain (p <0.05) (116.8 ± 13.8 vs 148.4 ± 14.61, 251.1 ± 8.9 vs 185.8 ± 8.6 and 293.3 ± 16.6 vs 221.2 ± 6.0 ml for first rectal sensation, desire to defecate and rectal pain, respectively). Four and 6 months after surgery, rectal compliance and sensitivity returned to levels similar to those in the basal period. Muscle tissue was found in only three of the 10 resected doughnuts. Controls remained without any change in rectal compliance and sensitivity. Stapled haemorrhoidopexy transiently decreases rectal compliance and sensitivity threshold in young male patients.

Submucosal electrocoagulation for prolapsed hemorrhoids:a new operative approach to hemorrhoidal varices.

The results of submucosal electrocoagulation (SEC), a new radical operation for prolapsed hemorrhoids, in 403 patients with third- or fourth-degree hemorrhoids are reported. After resecting the anal skin tags that coexisted with prolapsed hemorrhoids, the hemorrhoidal varices could be resected and electrically coagulated through the wound without cutting the anal canal epithelium by using a fine needle-type electric knife. The results of this series indicated that SEC could dramatically reduce the incidence of the postoperative complications that sometimes occur after conventional hemorrhoidectomy, such as severe anal pain, massive anal bleeding and anal stenosis. Moreover, SEC could ensure that operated patients make an early return to social activities and have a satisfactory quality of life. Relapse of prolapsed hemorrhoids after SEC was rare.

Our criteria for PPH procedure in one day surgery practice

BackgroundThe aim of this report is to analyse our results and to underline our criteria for day surgery practice.Patients and methodsOur patients are selected according to ASA criteria. Occasionally, the patients with some risk factors are selected but only when their concomitant diseases are well controlled.ResultsWe have treated 673 patients with the third and early fourth degree haemorrhoids. We have had patients with several minor problems causing no influence on the success of the procedure. Good haemostasis, preventing postoperative bleeding, is the most important factor.ConclusionAmong proctological procedures in haemorrhoid treatment, the PPH technique has firm and well-accepted position even in ambulatory surgery.

7th Biennial Congress of the Mediterranean Society of Coloproctology (MSCP), Thessaloniki, Greece, April 22–24, 2010

I attended a well-organized meeting, with the participation of many speakers from Greece, from the Mediterranean area and from several European countries, despite the ashes of the Icelandic volcano. Topics included the most relevant aspects of coloproctological research. A friendly but frank atmosphere has characterized the comprehensive discussion in every session. The optimal diagnostic work-up of rectal cancer was stressed. Endorectal ultrasound can accurately predict T stage in more than 90% of cases, but it is poor at identifying the N stage. CT is useful for locally advanced tumors in identifying adjacent organ involvement, but it cannot accurately evaluate the T stages. MRI is able to accurately predict T stage in 50–90% of patients but is the most reliable tool to detect the circumferential margin involvement. Accuracy in identifying peritoneal tumor perforation and venous invasion is up to 80 and 83%, respectively (M.G. Pramateftakis, I. Kanellos). Total mesorectal excision is the gold standard in the treatment of rectal cancer. Additionally, high ligation of colonic arteries and complete mesocolon excision was presented as the optimal surgical technique of right hemicolectomy for colon cancer (M.G. Pramateftakis). Minimally invasive local excision techniques can be applied for early T1 and T2 rectal tumors smaller than 4 cm, involving less than 40% of the lumen circumference, in patients with significant comorbidities to undergo a radical procedure, in symptomatic patients with multi-organ distant metastatic disease and in well-informed patients denying a radical procedure or a stoma (K. Tepetes). Leakage of colonic anastomosis is the most serious complication after colon resection. Early diagnosis and treatment is imperative; minor leaks can be treated conservatively with parenteral nutrition and antibiotics, while operative treatment is needed for major leaks defined by symptoms of peritonitis and septicemia (D. Kanellos). Loco-regional recurrences of colon cancer (tumor bed, regional nodes, adjoining structures or organs, anastomosis, peritoneum, retroperitoneum, pelvis and surgical scars) after curative colon cancer range between 11 and 40% and are responsible for 30% of deaths. The ideal treatment is the complete resection of the recurrence tumor to achieve R0 operation that provides significant long-term survival (A.N. Machairas). GISTs are the most common mesenchymal gastrointestinal tumors. The most common sites are the stomach and the small bowel. Colorectal GISTs represent 5–10% of the cases, with rectum being the most common site. Segmental colectomy is the mainstay of treatment for resectable nonmetastatic primary colorectal GIST. Since GIST do not metastasize through lymphatics, lymphadenectomy and mesorectal excision are not necessary. Unresectable tumors could be downstaged with neoadjuvant treatment and restaged for respectability (A. Amato). Firstand second-degree hemorrhoids should be treated conservatively. Stapled hemorrhoidopexy is indicated for third-degree hemorrhoids. The technique is questionable for fourth-degree hemorrhoids, showing a higher long-term recurrence rates than excisional surgery (I. Kanellos, X. Delgadillo). Obstructed defecation affects nearly 50% of constipated patients. Symptoms include incomplete and frequent evacuations, straining at stool, self-digitation, perineal and pelvic heaviness, long time spent in toilette. Rectocele and rectal mucosal prolapse are the most common findings, E. Yiannakopoulou (&) Faculty of Health and Caring Professions, Technological Educational Institute of Athens, Athens, Greece e-mail: nyiannak@teiath.gr

Harmonic Scalpel ® compared with bipolar electro-cautery hemorrhoidectomy: A randomized controlled trial

Introduction Surgical excision using Harmonic Scalpel ® is a modern technique used for ablation of symptomatic third degree and all fourth-degree hemorrhoids. Compared with electrocautery, Harmonic Scalpel ® causes minimal lateral thermal injury during tissue dissection. The resulting mucosal defect is then either left open or sutured (closed) depending on surgeon preference. The aim of this work was to evaluate the value of using Harmonic Scalpel ® in reducing incidence of postoperative complications following Hemorrhoidectomy. Patients & Methods This is a single-blind randomized controlled trial done at Zagazig University hospital during the period from July 2007 to December 2008. Patients underwent surgical excision of complex grade III or grade IV hemorrhoids. They were divided into two groups: (A) Harmonic Scalpel ® Hemorrhoidectomy group and (B) Bipolar Electro-cautery Hemorrhoidectomy group. Pain levels scoring and postoperative complications were analyzed. Results Postoperative pain in Group (A) was significantly less with less analgesic requirement. There was no significant difference between both groups regarding other postoperative complications. Conclusion This study demonstrates significantly reduced postoperative pain after Harmonic Scalpel ® Hemorrhoidectomy compared with bipolar electro-cautery Hemorrhoidectomy. Most likely, this result came from the avoidance of excessive lateral thermal injury caused by bipolar electrocautery.

Transanal Hemorrhoidal Dearterialization: A Systematic Review

Transanal hemorrhoidal dearterialization consists of a Doppler-guided ligation of the distal branches of the rectal arteries. The aim of this review is to assess the current evidence on dearterialization, establish the safety and efficacy of the technique, define its indications, and identify its possible advantages and limitations. All published studies on dearterialization without language restrictions were reviewed systematically. Primary outcome measures were postoperative pain and hemorrhoidal recurrences. Seventeen articles including a total of 1,996 patients were analyzed. In general, the quality of the studies was low. Operating time ranged between 5 and 50 minutes. Hospital stay was one day for most patients, whereas the return to normal activities was between two and three days in most cases. Postoperative pain was present in 18.5% of patients. Three patients experienced significant postoperative hemorrhages. There were no other major complications. The overall recurrence rate was 9.0% for prolapse, 7.8% for bleeding, and 4.7% for pain at defecation. The recurrence rate at one year or more was 10.8% for prolapse, 9.7% for bleeding, and 8.7% for pain at defecation. When reported as a function of the hemorrhoidal grade, the recurrence rate was higher for fourth-degree hemorrhoids (range, 11.1-59.3%). Transanal hemorrhoidal dearterialization appears to be a potential treatment option for second-degree and third-degree hemorrhoids. Clinical trials and longer follow-up comparing it with other procedures used to treat hemorrhoids are needed to establish a possible role for this technique.

Rectal Distensibility and Symptoms After Stapled and Milligan–Morgan Operation for Hemorrhoids

IntroductionIn a previous uncontrolled study, a reduction of rectal distensibility and volume thresholds for sensations have been related to the occurrence of fecal urgency and/or increased stool frequency after stapled hemorrhoidopexy. Aim of the studyThe aim of this study was to compare rectal symptoms and sensory-motor function after stapled hemorrhoidopexy and Milligan–Morgan hemorrhoidectomy. MethodsThe clinical records of 12 (four women) and ten patients (four women) with third- and fourth-degree hemorrhoids, respectively, who underwent stapled hemorrhoidopexy or Milligan–Morgan’s hemorrhoidectomy, were evaluated. One week before and 6 months after surgery, rectal motor and sensory response to distension was assessed by an electronic barostat, and bowel and rectal symptoms were recorded by means of a 7-day diary and Bristol Index scale and psychological symptoms with SCL-90 questionnaire. ResultsRectal distensibility and volume thresholds for sensations were significantly lower after surgery (P < 0.02) in the stapled group. Increased stool frequency and/or fecal urgency arose in 41% of patients in the stapled group and associated with altered rectal distensibility. No difference within and between groups could be demonstrated in SCL-90 score. ConclusionsRectal distensibility and volume thresholds for sensations decrease after stapled hemorrhoidopexy. Altered rectal distensibility was associated with rectal urgency and/or increased stool frequency.

Doppler guided haemorrhoidal arterial ligation with recto‐anal‐repair (RAR) for the treatment of advanced haemorrhoidal disease

A modification of Doppler guided haemorrhoidal artery ligation (DGHAL) to include the addition of recto-anal repair is reported. Preliminary results of function and safety of third and fourth degree haemorrhoidals are given. Thirty patients underwent DGHAL combined with recto-anal-repair (RAR). Each had rectal examination, anorectal manometry and Quality of Life assessment before and 3 months after the procedure. Twenty-nine patients were included in the final analysis. There were three (10.34%) patients of intra-operative and one (3.45%) of postoperative bleeding. Three months after RAR (17.24%) patients with minor residual mucosal prolapse were detected, three (10.34%) patients reported residual symptoms. There was no case of recurrent bleeding. Anal manometry at 3 months after RAR was significantly lower than before the procedure (P < 0.05). One (3.45%) patient reported occasional soiling 3 months after RAR. Recto-anal-repair is safe in treating third and fourth degree haemorrhoids with no major complications and low rate of residual disease.

A Comparison of Open versus Closed Techniques Using the Harmonic Scalpel in Outpatient Hemorrhoid Surgery

Surgical excision using the Harmonic Scalpel is a modern technique for symptomatic third- and fourth-degree hemorrhoids. The resulting mucosal defect is then left open or sutured closed depending on surgeon preference. The purpose of this study was to compare the open vs. closed techniques of hemorrhoid excision using the Harmonic Scalpel in an outpatient setting. From July 2000 through October 2001, 42 patients underwent surgical excision of complex grade III or grade IV hemorrhoids via the Harmonic Scalpel with closure of the overlying mucosa (closed), and without closure of the overlying mucosa (open). Quality of life was assessed using the Short Form-36 survey. Both groups were comparable in terms of patient demographics and type of anesthesia. There were no late complications. Mean follow-up was 16.9 (range, 12-27) months. Leaving the mucosal defect open following Harmonic Scalpel hemorrhoidectomy significantly reduces operative time, and thus operative costs, without diminishing quality of life. Although morbidity was equivalent, this requires further evaluation with a prospective study to ensure patient safety.

Randomized clinical trial comparing LigaSure haemorrhoidectomy with open diathermy haemorrhoidectomy

Background Milligan-Morgan excision haem-orrhoidectomy remains a very popular treatment modality for third and fourth degree haemorrhoids due to its cost effectiveness and good long-term results. The LigaSure tissue-sealing device is an alternative technique used in haemorrhoidectomy that has been shown to produce favourable results. The aim of this study was to assess the effectiveness of the LigaSure tissue sealing device in comparison with conventional diathermy haemorrhoidectomyMethods A prospective clinical trial was conducted. Patients with newly diagnosed haemorrhoids requiring haemorrhoidectomy were randomized to either LigaSure haemorrhoidectomy or diathermy haemorrhoidectomy. Surgical technique and postoperative care was standardized. Outcome measures were operative time and bleeding, postoperative pain (measured on a visual analogue scale) and rate of wound healingResults We randomized 44 patients, 22 to LigaSure and 22 to diathermy; 43 patients were evaluated. They were aged between 19 and 71 years. There were no differences in patient demographics or type of haemorrhoid being operated on. LigaSure haemorrhoidectomy had a significantly lower mean operative time and intraoperative bleeding. At 3 weeks after surgery, haemorrhoidectomy performed with LigaSure had an odds ratio for complete epithelialization of 3.1 over diathermy (95% CI 1.2–8.2). There was no difference in postoperative painConclusion LigaSure haemorrhoidectomy is superior to diathermy for open haemorrhoidectomy

Evaluation of Rectal Sensory and Motor Function by Means of the Electronic Barostat After Stapled Hemorrhoidopexy

Stapled hemorrhoidopexy is designed to replace the hemorrhoids into the anal canal by excising the redundant rectal mucosa above the anorectal ring, thus resulting in an intrarectal suture. Few studies have evaluated rectal function after this procedure. This prospective study was designed to use the electronic barostat to assess whether rectal motor and sensory functions change after stapled hemorrhoidopexy. Ten patients (4 women, mean age, 46 +/- 9 years) with third-degree and fourth-degree hemorrhoids who underwent stapled hemorrhoidopexy were studied. One week before and six months after surgery, they underwent three different rectal distensions (pressure-controlled stepwise, volume-controlled stepwise, and ramp) controlled by an electronic barostat. Rectal distensibility was significantly lower after surgery during pressure stepwise (P = 0.01), during volume stepwise (P = 0.006), and during ramp distension (P = 0.001). Volume thresholds for desire to defecate, urgency, and discomfort were significantly lower after surgery during all three distensions (P < 0.05). Volume threshold for first perception also was significantly lower after surgery during volume ramp distension (P = 0.01). Rectal distensibility and volume thresholds for sensations decrease after stapled hemorrhoidopexy. These impairments persist for at least six months after surgery.

Stapled haemorrhoidectomy (haemorrhoidopexy) for the treatment of haemorrhoids: a systematic review and economic evaluation

To determine the safety, clinical effectiveness and cost-effectiveness of circular stapled haemorrhoidopexy (SH) for the treatment of haemorrhoids. Main electronic databases were searched up to July 2006. Randomised controlled trials (RCTs) with 20 or more participants that compared SH with any conventional haemorrhoidectomy (CH) technique in people of any age with prolapsing haemorrhoids for whom surgery is considered a relevant option, were used to evaluate clinical effectiveness. An economic model of the surgical treatment of haemorrhoids was developed. The clinical effectiveness review included 27 RCTs (n = 2279; 1137 SH; 1142 CH). All had some methodological flaws; only two reported recruiting patients with second, third and fourth degree haemorrhoids, and 37% reported using an appropriate method of randomisation and/or allocation concealment. In the early postoperative period 95% of trials reported less pain following SH; by day 21 the pain reported following SH and CH was minimal, with little difference between the two techniques. Significantly fewer patients had unhealed wounds at 6 weeks following SH [odds ratio (OR) 0.08, 95% confidence interval (CI) 0.03 to 0.19, p < 0.001]. Residual prolapse was more common after SH (OR 3.38, 95% CI 1.00 to 11.47, p = 0.05, nine RCTs, results of a sensitivity analysis). There was no difference between SH and CH in the incidence of bleeding or postoperative complications. SH resulted in shorter operating times, hospital stay, time to first bowel movement and return to normal activity. In the short term (between 6 weeks and a year) prolapse was more common after SH (OR 4.68, 95% CI 1.11 to 19.71, p = 0.04, six RCTs). There was no difference in the number of patients complaining of pain between SH and CH. In the long term (1 year and over), there was a significantly higher rate of prolapse after SH (OR 4.34, 95% CI 1.67 to 11.28, p = 0.003, 12 RCTs). There was no difference in the number of patients experiencing pain, or the incidence of bleeding, between SH and CH. There was no difference in the total number of reinterventions, or reinterventions for pain, bleeding or complications, between SH and CH. Significantly more reinterventions were undertaken after SH for prolapse at 12 months or longer (OR 6.78, 95% CI 2.00 to 23.00, p = 0.002, six RCTs). Overall, there was no statistically significant difference in the rate of complications between SH and CH. In the economic assessment it was found that, on average, CH dominated SH. However, CH and SH had very similar costs and quality-adjusted life-years (QALYs). On average, the difference in costs between the procedures was 19 pounds and the difference in QALY was -0.001, favouring CH, over 3 years. In terms of QALYs, the superior quality of life due to lower pain levels in the early postoperative period with SH was offset by the higher rate of symptoms over the follow-up period, compared with CH. The results are very sensitive to modelling assumptions, particularly the valuation of utility in the early postoperative period. The probabilistic sensitivity analysis showed that, at a threshold incremental cost-effectiveness ratio of 20,000-30,000 pounds per QALY, SH had a 45% probability of being cost-effective. SH was associated with less pain in the immediate postoperative period, but a higher rate of residual prolapse, prolapse in the longer term and reintervention for prolapse. There was no clear difference in the rate or type of complications associated with the two techniques and the absolute and relative rates of recurrence and reintervention for both are still uncertain. CH and SH had very similar costs and QALYs, the cost of the staple gun being offset by savings in hospital stay. Should the price of the gun change, the conclusions of the economic analysis may also change. Some training may be required in the use of the staple gun; this is not expected to have major resource implications. Given the currently available clinical evidence and the results of the economic analysis, the decision as to whether SH or CH is conducted could primarily be based on the priorities and preferences of the patient and surgeon. An adequately powered, good-quality RCT is required, comparing SH with CH, recruiting patients with second, third and fourth degree haemorrhoids, and having a minimum follow-up period of 5 years to ensure an adequate evaluation of the reintervention rate. Other areas for research are the effectiveness of SH in patients with fourth degree haemorrhoids and patients with co-morbid conditions, the reintervention rates for all treatments for haemorrhoids, utilities of patients up to 6 months postoperatively, the trade-offs of patients for short-term pain versus long-term outcomes, and the ability of SH to reduce hospital stays in a real practice setting.

HAEMORRHOIDECTOMY WITH ELECTROCAUTERY OR ULTRASHEARS AND STAPLED HAEMORRHOIDOPEXY

This study evaluated in a randomized, prospective manner the possible differences in operative time, postoperative pain and analgesic requirement, early complications, time off-work and patient satisfaction between patients undergoing haemorrhoidectomy using the electrocautery (ECH), UltraShears (ultrasonically activated scalpel; USH) or stapled haemorrhoidopexy (SH). Patients with symptomatic third-degree or fourth-degree haemorrhoids were randomized into one of the three groups: ECH, SH (PPH stapler; Ethicon Endo-Surgery, Cincinnati, OH, USA) or USH groups. The operative times and complications, if any, were recorded. An identical anaesthetic technique was used for all patients, and postoperative analgesia was also standardized according to the pain scores. Pain was evaluated preoperatively and at 8 and 24 h and 2, 7, 14 and 28 days, postoperatively, by means of a visual analogue scale. The numbers of narcotic and non-narcotic analgesics used, the time required for full return to daily activities and the incontinence scores at 4 months postoperatively were evaluated, as well as patient satisfaction. No significant differences with respect to age or sex existed between the three groups, each consisting of 20 patients. USH was significantly faster than both ECH and SH (P < 0.0001 for both comparisons) in operation time, and SH was faster than ECH (P < 0.0001). Comparing any two groups, the mean pain scores in the ECH group were significantly higher than in the SH and USH groups at postoperative 8 and 24 h, and day 2, but the groups reached comparable pain scores at day 7, 14 and 28. The numbers of narcotic and non-narcotic analgesics used in the ECH group were significantly higher than in the SH and USH groups (P < 0.0001 for all comparisons). The early postoperative complication rate was higher in the ECH group (25%), compared with the SH (P = 0.017) and USH (P < 0.0001) groups. Only 12 patients (60%) in the ECH group could be discharged within the first postoperative 24 h, whereas all of the patients (100%) in the SH and 17 patients (85%) in the USH groups could be treated as day cases. The time required for full return to daily activities was similar in the SH and USH groups (P = 0.841), but it was significantly longer in the ECH group (P < 0.0001 for both comparisons). The 70% patient satisfaction rate in the ECH group was significantly lower than in the SH (95%; P = 0.008) and the USH (100%, P = 0.002) groups. Our short-term results have shown that SH and ultrasonic dissector haemorrhoidectomies were superior to ECH haemorrhoidectomy, in terms of surgical utility, postoperative pain, analgesic intake, time off-work and patient satisfaction. Some advantages of USH over SH also appeared.