Procedure For Prolapsed Hemorrhoids Research Articles

Correlation Between Poor Defecation Habits and Postoperative Hemorrhoid Recurrence.

BackgroundThe relationship between hemorrhoid recurrence and poor defecation habits is poorly understood. This study aimed to analyze the effects of poor defecation habits on postoperative hemorrhoid recurrence.Materials and MethodWe performed a retrospective study on 1,162 consecutive patients who underwent a surgical procedure for hemorrhoids at the Sixth Affiliated Hospital of Sun Yat-Sen University from December 2016 to May 2020. All patients were followed for 12 months post-operatively. Patients were monitored for disease recurrence. Patient defecation habits were assessed using an obstructive defecation syndrome (ODS) score.ResultsPatients with a score of 0–4 had a mild defecation disorder, 5–8 a moderate defecation disorder, and 9 or more ODS. Of the 1,162 patients, 1,144 (98.45%) had a mild defecation disorder, 13 (1.12%) had a moderate defecation disorder, and 9 (0.43%) had ODS. Older patients were significantly more likely to have worse defecation habits (P < 0.001). A higher ODS score correlated with a higher maximum anal squeeze pressure (P = 0.07) and a more severe inability for the anus to relax during simulated evacuation (P = 0.002). The maximum rectum threshold was also found to be the highest in ODS patients (P = 0.010). The proportion of Procedure for prolapsing hemorrhoids (PPH) was the highest in the moderate defecation disorder group (53.85), followed by the ODS group (40.00) and the mild defecation disorder group (P = 0.023). Recurrence occurred in 5.51% of patients in the mild defecation disorder group, 38.46% of the moderate defecation disorder group, and 60% of the ODS group (P < 0.001). Multivariate analysis confirmed a higher ODS score (P < 0.001) was an independent predictor of recurrence. Furthermore, patients who occasionally exercised (P = 0.01) and patients who exercised regularly (P = 0.021) were less likely to have a recurrence.ConclusionPatients with unresolved defecation disorders are more likely to have their hemorrhoids recur and are unlikely to be satisfied with surgical management.

Indications, Feasibility, and Safety of TST STARR Plus Stapler for Degree III Hemorrhoids: A Retrospective Study of 125 Hemorrhoids Patients

BackgroundStapler hemorrhoidopexy (SH) has been widely accepted for hemorrhoids patients because of its low postoperative pain, but it is also associated with a high recurrence rate. The recurrence might be due to failure to completely remove the prolapsed tissue or insufficient removal capacity of the instruments. Removing more prolapsed tissue to reduce the recurrence is believed to benefit more severe prolapsed hemorrhoids patients.MethodsWe evaluated the short- and long-term safety and efficacy in 125 hemorrhoids patients who underwent SH in 2013–2015. Eighty patients had prolapsed tissue less than half of the circular anal dilator (CAD) and underwent a procedure for prolapsing hemorrhoids (PPH), while the remaining 45 patients with hemorrhoid prolapse greater than half of the CAD were treated with a tissue selection therapy stapler stapled transanal rectal resection plus (TST STARR+).ResultsThere were no significant differences between the two groups in terms of operative time, hospitalization time, overall satisfaction or complications. At follow-up of up to 4 years after surgery, there was no significant difference in recurrence rates between TST STARR+ group and PPH group (5.2% vs. 4.7%, p < 0.05). The mean width and volume of the resected tissues were significantly larger in the TST STARR+ group than in the PPH group (4.8 vs. 2.9 cm, 10.2 vs. 4.4 cm3, P < 0.05).ConclusionThe TST STARR+ procedure can remove more hemorrhoidal tissue than PPH and it is better suited for patients with severe annular prolapsed hemorrhoids greater than half of the CAD. It has the advantages of convenient to operate, rapid recovery, fewer complications, and long-term satisfactory results.

Randomized Trial of Open Hemorrhoidectomy Versus Stapled Hemorrhoidectomy for Grade II/III Hemorrhoids

Hemorrhoids are one of the most common anorectal disorders. Open hemorrhoidectomy (OH) is the gold standard surgical technique while stapled hemorrhoidopexy (SH) [procedure for prolapsed hemorrhoids (PPH)] is a newly developed method for the surgical management of hemorrhoids. A Medline, PubMed, and Cochrane data base search was performed. Relevant papers, e.g., randomized controlled trials, review, and meta-analysis from different parts of the world have shown stapled hemorrhoidopexy is less painful and it is associated with quicker recovery, but SH is associated with higher rates of skin tags, hemorrhoid recurrence, and prolapse recurrence than conventional hemorrhoidectomy. A randomized trial was conducted from March 2014 to March 2016 at M.Y.H. Hospital Indore tertiary care center. The aim of the study was to compare the early results in 100 patients randomly allocated to undergo either stapled or open hemorrhoidectomy. Patients with grade II and III hemorrhoids were randomly allocated to undergo either stapled (50 patients) or open (50 patients) hemorrhoidectomy. Post-operative pain was assessed by means of a visual analog scale (VAS). Recovery evaluation included return to pain-free defecation and normal activities. A 6-month clinical follow-up was obtained in all patients. Operation time for stapled hemorrhoidectomy was shorter (mean 35.8 mins [range 20 to 50] minutes versus 50.2 mins [range 30 to 60] minutes, p < 0.05). Mean (range) VAS scores in the stapled group were significantly lower (VAS score after 7 days: 2.2 [2 to 5] versus 3.3 [2 to 6], p < 0.05). Resumption of routine work was significantly faster in the stapled group (8.08 days versus 16.2 days, p = 0.001). At follow-up, 4 weeks and 4 months recurrence of symptoms and fecal urgency was present in 6/50 (12%) patients in the stapled group and 2/50 (4%) in the OH group (p < 0.05). Our initial results suggest that stapled hemorrhoidectomy is an effective treatment for symptomatic second and third degree hemorrhoids but with significant complication rates on follow-up in patients compared with traditional hemorrhoidectomy.

Haemorrhoidectomy- stapler versus conventional (open): our experience

Background: Haemorrhoids is a common disease affecting humans. Surgical treatment of haemorrhoids includes by using stapler and conventional or open method. Both the methods have its own advantages and disadvantages. This study is done to evaluate the efficacy of both the procedures in our settings. Objective of the study was to study the efficacy of two surgical methods of treatment of hemorrhoids, in terms of (1) operation time; (2) post-operative pain; (3) hospital stay; (4) return to normal activity and return to work; (5) complications; (6) recurrence; (7) patient satisfaction. Methods: A comparative study was done between open and stapling methods for the treatment of symptomatic hemorrhoids in CMCH, Bhopal, India over a period from November 2011 to December 2014. Results: There was major statistically significant difference was seen among different parameters between these two procedures of haemorrhoidectomy, open versus stapler procedure for prolapsing hemorrhoids (PPH). Conclusions: In present study there is definite difference noted between two surgical methods as evident from table 1- 10 as evident from p-value. As far as satisfaction of patient is considered in both the groups satisfaction is similar except for the cost of device which added for the most cause of dissatisfaction.

How long to stay in hospital: Stapled versus open hemorrhoidectomy?

Background: Haemorrhoids is a common condition seen in general surgery practice. Treatment includes many methods ranging from rubber band ligation, infrared photocoagulation, sclerotherapy to stapler hemorrhoidectomy. Our study is done to evaluate the efficacy of both the procedures in a rural setting. Objectives of the study was to study the efficacy of two surgical methods of treatment of hemorrhoids, in terms of (1) operation time; (2) post-operative pain; (3) hospital stay; (4) return to normal activity and return to work. Methods: A comparative study was done between open and stapling methods for the treatment of symptomatic hemorrhoids in Al Azhar Medical College, Thodupuzha, India. Results: There was major statistically significant difference seen among different parameters between the two procedures of haemorrhoidectomy, open versus stapler procedure for prolapsing hemorrhoids (PPH) as evident from the p value. Conclusions: In our study there is a definite difference noted between two surgical methods in terms of hospital stay and return to work. As far as satisfaction of patient is considered in both the groups satisfaction is similar except for the cost of surgery which was the only cause of dissatisfaction.

Proctitis after stapled hemorrhoidopexy is an underestimated complication of a widely used surgical procedure: a retrospective observational cohort study in 129 patients

BackgroundHemorrhoidal disease is highly prevalent in the western world. Stapled hemorrhoidopexy also known as the procedure for prolapsed hemorrhoids (pph) has been shown to be superior to conventional hemorrhoidectomy with regard to postoperative pain, length of hospital stay and early return to work. Proctitis following stapled hemorrhoidopexy has not been reported previously. Herein, we report our experience with proctitis in patients following stapled hemorrhoidopexy and question if proctitis could be a complication of stapled hemorrhoidopexy.Materials and methodsA retrospective analysis of the data of patients undergoing stapled hemorrhoidopexy with the PPH03 in the coloproctology unit of the department of surgery of a primary care hospital in Germany within a 5-year period was performed. All cases were managed and followed up by a single attending surgeon with expertise in coloproctology.Results129 patients were included for analysis including 21 cases with grade 2, 103 cases of grade 3 and 5 cases of grade 4 hemorrhoids. The median duration of surgery was 20 min. 17 complications including two recurrences were recorded. Post-pph proctitis was recorded in 14 cases (10.9 %). Post-pph proctitis was not associated with gender, extent of hemorrhoidal disease, BMI and ASA (p >0.05). All cases recovered within 4 weeks following management with nonsteroidal anti-inflammatory drugs and suppositories.ConclusionProctitis could be a complication of stapled hemorrhoidopexy with a good response to conservative treatment with suppositories.

Complications after procedure for prolapse and hemorrhoids in treating severe mucocutaneous hemorrhoids

Objective To analyze the complications after procedure for prolapse and hemorrhoids (PPH) in treating severe mucocutaneous hemorrhoids.Methods The clinical data of 550 patients with severe mucocutaneous hemorrhoids who were admitted to the Hangzhou Hospital of Nanjing Medical University from January 2005 to December 2013 were retrospectively analyzed.All the patients were treated by PPH or PPH + external hemorrhoids resection.The postoperative complications were recorded and assessed.Patients were followed up via outpatient examination and telephone interview till June 2014.Results Operation was successfully carried out on all the 550 patients.The operation time and duration of hospital stay were (15 ± 10)minutes and (4.2 ± 1.8)days,respectively.A total of 445 patients were followed up for 6-60 months,with the median time of 28 months.The overall incidence of complications was 14.61％ (65/445).Forty-five patients were complicated with anal pain,12 with hemorrhoid recurrence,7 with bleeding,5 with dysporia,4 with anastomotic stenosis and 2 with rectal and perianal infection.Of the 12 patients with hemorrhoids recurrence,5 was alleviated by medication and 7 received PPH for the second time.Of the 4 patients with anastomotic stricture,the condition of 2 patients were alleviated by anus dilatation,and the condition of 1 patient was alleviated by balloon dilatation under enteroscope,1 patient received circular incision of the stricture because of severe stricture and failed of conservative treatment.Of the 2 patients with rectal and perianal infection,1 was alleviated by intravenous and local medication,and the other patient who was complicated with anal fistula was alleviated by surgery.The condition of other patients was improved after symptomatic treatment.Conclusions PPH is effective and safe for the treatment of severe mucocutaneous hemorrhoids.The main complication is anal pain,and it could be cured or alleviated by symptomatic treatment. Key words: Severe mucocutaneous hemorrhoids; Procedure for Prolapsed Hemorrhoids; Complications

Severe intra-abdominal bleeding leading to hemorrhagic shock, rectal perforation, and bilateral hydrothorax after stapling procedure for prolapsed hemorrhoids (PPH): is the transanal drainage feasible in this situation?

Severe intra-abdominal bleeding leading to hemorrhagic shock, rectal perforation, and bilateral hydrothorax after stapling procedure for prolapsed hemorrhoids (PPH): is the transanal drainage feasible in this situation?

Iatrogenic Rectal Diverticulum With Pelvic-Floor Dysfunction in Patients After a Procedure for a Prolapsed Hemorrhoid

Diverticula are frequently seen in the sigmoid, descending, ascending and transverse colons whereas rectal diverticula are extremely rare. The stapled rectal mucosectomy for the treatment of a prolapsed hemorrhoid is less painful and has lower morbidity; therefore, it has been commonly used despite possible complications. This paper reports a case of a rectal diverticulum that developed after a procedure for prolapsed hemorrhoids (PPH). A 42-year-old man with a history of hemorrhoidectomies came to the hospital because of constipation. On sigmoidoscopy, a 2-cm-sized, feces-filled pocket was located just above the anorectal junction. After removal of the fecal material, a huge rectal diverticulum (-4 cm in diameter) was seen. Pelvic magnetic resonance imaging (MRI) confirmed the diagnosis of rectal diverticulum outpouching through the muscular layer of the intestine in a left posterolateral direction. The patient was discharged without complication after a transanal diverticulectomy had been performed, and the direct rectal wall had been repaired.

Histopathology and Physiological Alterations After Procedure for Prolapsed Hemorrhoids

See Article on Page 198-204 Since the introduction of procedure for prolapsed hemorrhoids (PPH) into the treatment of hemorrhoids, PPH has been accepted as a standard treatment that can replace the conventional hemorrhoidectomy. However, some safety concerns were raised during the early period of its introduction into clinical practice. One of the concerns was the presence of smooth muscle in the resected specimen. The clinical importance of smooth muscle tissue in the specimen is possible injury to the internal sphincter and deterioration in continence. Even striated muscles have been reported in PPH specimens [1, 2]. These findings mean that the rectal wall or internal sphincters, as well as external sphincters, may be damaged during PPH. Many researchers have focused on the above issue and have tried to determine if this histological finding has any clinical significance for the postoperative functional outcome. The incidence of smooth muscle being observed in specimens after PPH ranged from 20% to 100% [3-5] while no significant manometric changes or deterioration in continence was observed. To date, the clinical significance of the smooth muscle in the PPH specimen is still not clear. Some authors have tried to correlate the amount of the smooth muscle in the PPH specimen to a decrease in manometric results [1]. However, a decrease in the resting pressure is observed not only after a PPH but also after a conventional hemorrhoidectomy [6]. Also, the presence of smooth muscles in the PPH specimen does not always mean an injury to the internal sphincter. Currently, it is impossible to differentiate the smooth muscles of rectum from the internal sphincter. It is more probable that the rectal proper muscle, rather than the internal sphincter, may be injured during a PPH because it is recommended to perform the procedure two to five centimeters above the dentate line [7]. If the staple line is at the level of the dentate line and the specimen involves smooth muscle, one can conclude that an injury to the internal sphincter happened during the PPH. However, there was no change in continence, not even in cases where an injury to the internal sphincter was highly suspected because the smooth muscles had been resected from the anal sphincter region. On the other hand, there have been reports that these inadvertent histological findings may be a cause of pain, tenesmus, or fecal urgency [8]. Although the PPH is devised to remove mucosa and submucosa, smooth muscle in PPH specimens is a frequently-observed finding whose clinical significance is unclear. However, any injury to the continuity of the bowel or sphincter mechanism may lead to serious complications, such as retroperitoneal abscess, dehiscence, or deterioration of continence. Therefore, taking care not to injure the internal sphincter or the rectum so as to prevent unexpected serious complications is reasonable.

Obstructed defecation, rectocele, recurrent hemorrhoids, and rectal diverticulum following the PPH

The patient, a 64-year-old woman, underwent the procedure for prolapsed hemorrhoids (PPH), 8 years prior to presentation. Three years later, she began to suffer from obstructed defecation syndrome characterized by anal pain and rectal bleeding, and required continuous laxative treatment. A large rectocele (Figs. 1, 2, 3) retained staples (Fig. 1) and recurrent hemorrhoids (Fig. 4) were diagnosed preoperatively. In addition a large diverticulum was found intraoperatively (Fig. 5). The patient underwent removal of retained staples, laying open of the rectal diverticulum, rectocele repair and hemorrhoidectomy (Figs. 4, 5, 6, 7, 8). The patient’s symptoms markedly improved after 3 months.

Optimal Treatment of Symptomatic Hemorrhoids

Hemorrhoids are the most common anorectal complaint, and approximately 10 to 20 percent of patients with symptomatic hemorrhoids require surgery. Symptoms of hemorrhoids, such as painless rectal bleeding, tissue protrusion and mucous discharge, vary. The traditional therapeutic strategies of medicine include surgical, as well as non-surgical, treatment. To alleviate symptoms caused by hemorrhoids, oral treatments, such as fiber, suppositories and Sitz baths have been applied to patients. Other non-surgical treatments, such as infrared photocoagulation, injection sclerotherapy and rubber band ligation have been used to fixate the hemorrhoid's cushion. If non-surgical treatment has no effect, surgical treatments, such as a hemorrhoidectomy, procedure for prolapsed hemorrhoids, and transanal hemorrhoidal dearterialization are used.

Fecaloma in an iatrogenic diverticulum: an unusual complication of the procedure for prolapsed hemorrhoids (PPH)

The procedure for prolapsed hemorrhoids (PPH) is associated with low levels of postoperative pain but may be followed by unusual and severe postoperative complications. We report a case of a 62-year-old woman affected by tenesmus, obstructed defecation and vaginal bulging 2 years after a PPH procedure performed in another institution. Clinical examination and colonoscopy revealed a mass within the anterior rectal wall bulging into the vaginal and rectum lumen 3 cm above the dental line, mimicking a stromal tumor. Magnetic resonance imaging (MRI) confirmed the presence of an avascular mass, 4 cm in diameter, confined to the anterior rectal wall (Figs. 1, 2). Intraoperative findings revealed a calcified fecaloma enclosed in a mucousal rectal diverticulum communicating with the rectal lumen with a little opening at the level of the staple line (Figs. 3, 4).

Como o coloproctologista brasileiro vê a doença hemorroidária: análise de dados colhidos de questionário dirigido aos especialistas filiados à sociedade brasileira de coloproctologia

A análise das 52 respostas dadas pelos 77 especialistas ao questionário permite as seguintes conclusões: EPIDEMIOLOGIA: A média temporária de exercício profissional foi 18,6 anos; os 77 especialistas atenderam ± 1.097.860 pacientes, tendo diagnosticado DH em ± 393.763 (35,86%), tendo operado ± 102.400 pacientes (± 26%). A média aproximada de incidência de DH por gênero foi de 42% em homens e 58% em mulheres, e de hemorroidectomia de 43% em homens e 57% em mulheres, sendo as incidências de DH por faixas etárias: até 20 anos, 7%; de 21 a 40 anos, 40%; de 41 a 60 anos, 40%; e acima de 60 anos,13%. TRATAMENTO CLÍNICO E NÃO INTERVENCIONISTA: o tratamento clínico foi dispensado a ± 291.363, e ± 81,5% foram tratados com cuidados higiêno-dietéticos, pomadas e cremes. O tratamento intervencionista não cirúrgico de escolha foi a LE (94,0% dos especialistas), mais indicada em DH interna grau II (85,2%), com preferência de abordagem de um mamilo por sessão (74,1%), e preferência pela não realização de plicomectomia (67,1%), sendo os graus de satisfação ótimos e bons de 91 %. A LE foi feita em ± 48.273 pacientes (12,50%), tendo a maioria (42 médicos; 53,95%) negado complicações, destacando-se, dentre os que admitiram complicações, 69 casos de hemorragia que levaram à revisão (0,142% de 48.273 LE). HEMORROIDECTOMIA: a média anual foi de ± 80,34 cirurgias, totalizando 102.400, sendo a principal indicação cirúrgica a intensidade de sintomas independentemente do grau da DH (64,47%), com preferência pela técnica aberta de Milligan-Morgan (65,79%) seguida pela fechada de Ferguson (21,05%). A preferência anestésica absoluta foi pelos bloqueios raqueano (52,63%) e peridural (26,32%), os posicionamentos preferidos foram em canivete (44,73%) e ginecológica forçada (22,37%) e ginecológica (21,05%), e o regime preferido o hospitalar (78,94%), sendo 55,26% com pernoite (55,26%) e 23,68% sem pernoite. O uso de antibióticos foi preferido por 77,0%, sendo 47,0% em casos especiais e 30,0% de rotina, sobretudo a cefalosporina de segunda geração (13,0%) e associação de metronidazol com aminoglicosídeo (7,5%). PÓS-OPERATÓRIO: os antiinflamatórios (29,0%), paracetamol (21,5%), morfina (15,3%) e diclofenato sódico (13,0%) foram os analgésicos preferidos. O toque retal (TR) foi feito de rotina por 44 especialistas (57%), 34,5% como finalidade de detectar uma possível estenose e 25,5% para impedir o progresso de uma eventual estenose anal. Dentre as complicações pós-operatórias destacaram-se a hemorragia (52% dos especialistas) e a estenose anal (9% dos especialistas). 58 (75,0%) enviam o material, de rotina, para exame histopatológico; 55,52% não admitem cirurgias concomitantes à hemorroidectomia; 57,89% preferem o tratamento clínico em trombose hemorroidária. PPH: 35 (45%) nunca usaram e 38 já usaram o PPH (49%); dos 38 17 (22%) não continuaram a usá-lo e 21 continuaram; dos 35 especialistas que admitiram nunca ter usado o PPH, 62% não experimentaram e nem têm disposição para fazê-lo; dos 17 especialistas que experimentaram PPH, mas não continuarem a usá-lo, 42,85% por que não gostaram dos resultados, que são inferiores à técnica usada por cada um, 21,42% por que os custos são proibitivos e 21,42% por que os convênios não pagam; dos 42,85%. Nos 487 casos de PPH feitos por 12 especialistas foram necessárias aplicações de pontos extras em 55 pacientes (11,29%); foram observadas sete complicações pós-operatórias, das quais quatro estenoses (0,8%), duas hemorragias (0,4%) e um resultado insatisfatório com indicação de hemorroidectomia (0,2%).

Procedure for Prolapsed Hemorrhoids for Treatment of Rectal Mucosa Prolapse following Anorectoplasty for Imperforate Anus

Surgical management of imperforate anus and rectal mucosal prolapse has evolved significantly over the last two decades. The procedure for prolapsed hemorrhoids (PPH) is now widely used primarily for rectal mucosal prolapse and internal hemorrhoids. We describe the use of PPH in the management of symptomatic rectal mucosal prolapse in a 39-year-old man with a history of a high imperforate anus and pelvic floor reconstruction. At 4-year follow up, the prolapse has not recurred and the preoperative symptoms have resolved. To the best of our knowledge, this is the first report on the use of a PPH in the management of rectal mucosal prolapse in a patient with these characteristics.

Postoperative complications after procedure for prolapsed hemorrhoids (PPH) and stapled transanal rectal resection (STARR) procedures.

Procedure for prolapsing hemorrhoids (PPH) and stapled transanal rectal resection for obstructed defecation (STARR) carry low postoperative pain, but may be followed by unusual and severe postoperative complications. This review deals with the pathogenesis, prevention and treatment of adverse events that may occasionally be life threatening. PPH and STARR carry the expected morbidity following anorectal surgery, such as bleeding, strictures and fecal incontinence. Complications that are particular to these stapled procedures are rectovaginal fistula, chronic proctalgia, total rectal obliteration, rectal wall hematoma and perforation with pelvic sepsis often requiring a diverting stoma. A higher complication rate and worse results are expected after PPH for fourth-degree piles. Enterocele and anismus are contraindications to PPH and STARR and both operations should be used with caution in patients with weak sphincters. In conclusion, complications after PPH and STARR are not infrequent and may be difficult to manage. However, if performed in selected cases by skilled specialists aware of the risks and associated diseases, some complications may be prevented.

The Use of Alternative Energy Sources and New Techniques for the Treatment of Hemorrhoidal Disease

With the emergence of newer surgical technologies, the management of hemorrhoidal disease has both progressed and evolved. Although rubber band ligation (RBL), surgical hemorrhoidectomy, and the procedure for prolapsing hemorrhoids (PPH), remain useful and are commonplace in the treatment of hemorrhoids, newer alternative energy sources have provided the surgeon with a wide array of new and effective techniques for managing hemorrhoidal disease. In this paper, we shall review the basic principles underlying electrosurgery, as well as a variety of other newer modalities, and compare them to more traditional techniques of hemorrhoidectomy.

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

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. Five adult pigs underwent two PPH procedures in one session, leaving a ring of approximately 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. 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. 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.