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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 4  |  Issue : 3  |  Page : 108-112

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


1 Department of General Surgery, Al Azhar Medical College, Thodupuzha, Idukki District, Kerala, India
2 Department of Preventive Medicine, Al Azhar Medical College, Thodupuzha, Idukki District, Kerala, India
3 Biostatistician, Al Azhar Medical College, Thodupuzha, Idukki District, Kerala, India

Date of Web Publication14-Nov-2016

Correspondence Address:
Robinson George
Al Azhar Medical College, Ezhalloor, Thodpuzha - 685 605, Idukki District, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-3846.193985

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  Abstract 

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.

Keywords: Duration of stay, hemorrhoids, open hemorrhoidectomy, pain, stapled hemorrhoidopexy


How to cite this article:
George R, Vivek S, Suprej K. How long to stay in hospital: Stapled versus open hemorrhoidectomy?. Saudi Surg J 2016;4:108-12

How to cite this URL:
George R, Vivek S, Suprej K. How long to stay in hospital: Stapled versus open hemorrhoidectomy?. Saudi Surg J [serial online] 2016 [cited 2019 May 21];4:108-12. Available from: http://www.saudisurgj.org/text.asp?2016/4/3/108/193985


  Introduction Top


Hemorrhoids are a very common anorectal condition characterized as a symptomatic enlargement and distal displacement of the normal anal cushions. The exact etiopathology seems to be multifactorial and elusive including chronic constipation and chronic straining at stools. These are one of the oldest illnesses known to humanity. At least 50% of the people over the age of fifty have some degree of hemorrhoid formation. [1] Ferguson and Heaton said, "Hundred percent of the population does suffer from hemorrhoids at least once in their lifetime." [2] Open hemorrhoidectomy has stood the test of time and is the gold standard in the treatment of piles. This procedure has very few complications, with almost negligible rate of recurrence, but the patients are known to experience considerable pain in the postoperative period and which requires the absence from work for several days. There are numerous modalities of treatment, namely, rubber band ligation, infrared photocoagulation, bipolar diathermy, sclerotherapy, cryotherapy, hemorrhoidectomy (open/closed), anal dilation, pile stitching.

Among the newer ones, stapled hemorrhoidopexy performed using the circular anal stapler is probably said to decrease the postoperative pain, has shorter duration of hospital stay, and allows early return to work. This was a comparative study conducted in a rural medical college to compare the results of the conventional hemorrhoidectomy (open) with the stapled hemorrhoidopexy. The comparison was mainly done to ascertain the duration of stay in hospital.


  Materials and Methods Top


This comparative study had 100 patients which included fifty patients (stapled hemorrhoidopexy [n = 50]) and fifty patients (open hemorrhoidectomy [n = 50]), who were randomly put into two groups after explaining the risks and benefits of the two procedures.

The main inclusion criterion was symptomatic hemorrhoidal disease which could be treated by either conventional/open or stapled technique. The study was approved by the Institutional Ethics Committee and written and informed consent was taken from the patients.

Exclusion criteria were acute thrombotic hemorrhoidal episodes, history of prior hemorrhoidectomy, and intercurrent anal pathology (i.e., fistula and/or fissure).

EEA™ Hemorrhoid and Prolapse Stapler Set with DST Series™ Technology

The Covidien™ EEA™ Hemorrhoid and Prolapse Stapler Set with DST Series™ Technology is designed for use as a stapler instrument for control of rectal prolapse and hemorrhoid disease. The instrument places a circular, double-staggered row of titanium DST™ staples and removes a circular tissue specimen. The Covidien™ EEA™ Hemorrhoid and Prolapse Stapler Set with DST Series™ Technology is offered in a 33mm diameter size with either 3.5mm or 4.8mm staples.

The accompanying accessories are comprised of an access Port, Anoscope, and Dilator.

Pain was assessed using visual analog scale. The patients were followed up for 1 and 6 months.

The duration of stay in hospital was calculated in days.

Statistical analysis

Data were analyzed using SPSS 21.0 year 2011 (IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp) and graphs were depicted using Microsoft excel 2013 (Microsoft excel - developer Microsoft, operating system Windows XP, 12.0.4518.1014, USA). Quantitative data were summarized as mean with standard deviation or median with interquartile range. Qualitative data were summarized as frequency with percentage and analyzed using Chi-square test. Quantitative data between the groups were compared using independent sample t-test or Mann-Whitney U-test. For all tests, a P < 0.05 was considered statistically significant.


  Results Top


Age distribution of the patients

The mean age was 39.72 years for stapled hemorrhoidopexy and 40.26 years for open method. It was found that there is no difference in age between the treatment groups (P = 0.817). The youngest patient in this study was 22 years and the oldest was 67 years.

Sex distribution

The majority of patients included in the study were found to be predominantly male (55%). Of the 55 patients, thirty underwent stapled hemorrhoidopexy and 25 underwent open procedure. Of the 45 female patients, only twenty preferred stapled and 25 open.

Chief complaints

The predominant chief complaints were mass per rectum (92%), constipation (99%), straining at stools (98%), and painful defecation (99%).

Degree of hemorrhoids

In our study, 7 (2 male, 5 female) patients had Grade 2 hemorrhoids; 50 (30 male, 20 female) patients had Grade 3 hemorrhoids, and 43 (23 male, 20 female) patients had Grade 4 hemorrhoids.

Duration of surgery

The average time taken for surgery for stapled hemorrhoidopexy was 31.60 min and for open hemorrhoidectomy was 20 min (P = 0.000).

Duration of hospital stay

The average duration of hospital stay for the stapled group was 1 day and for open was 7 days (P = 0.000).

Return to work

The time taken to return to work in the stapled group was 7 days as against 20 days in the open group.

None of the patients in any of the groups had any postoperative wound infection.

Cost analyses

Conventional procedures were found to be cost-effective in our setting (Rs. 15,000 for open and Rs. 30,000 for stapled).


  Discussion Top


Stapled hemorrhoidopexy, as developed by Dr. Longo with use of a circular stapler, has emerged as a possible alternative to open hemorrhoidectomy. [3] According to a recently published consensus among experts, the technique has been standardized and is widely accepted in different countries. [4] The indications, contraindications, and operative technique have been defined. Numerous controlled studies have already demonstrated that this technique is associated with less postoperative pain and a quicker recovery. [5],[6],[7],[8],[9],[10],[11],[12]

Among the newer surgical options currently available, hemorrhoidectomy performed by the Longo-Milton technique using circular anal stapler is said to result in less postoperative pain and complications and early return to work. In this prospective study, we made a comparison between conventional hemorrhoidectomy (open) and the stapled technique with regard to duration of stay in the hospital.

Operating time

The operating time as found by us was much shorter in the open group (average 20 min) as compared to the stapled (average 31.60 min). Bikhchandani et al., [13] in a study comparing open with stapled procedure, found operating time and blood loss to be much lesser in the stapled group. Similar studies by Gravié et al. [14] and Mehigan et al. [6] yielded comparable results.

Stay in hospital

The duration of stay in hospital was much shorter in the stapled group (average 1 day) as compared to the open group (average 7 days).

Postoperative pain

Visual analog scores at 24 h postsurgery were significantly more favorable in the stapled group when compared to the open group. The reason for decreased pain in the stapled group is that it does not involve any surgery in the sensitive anal mucosa below the dentate line (the staple line is usually 4 cm above the dentate line). Mean pain scores in other studies have shown that the postoperative pain is less after stapled technique. We found that although the pain is higher in the conventional procedures in the immediate postoperative period, it comes down on the 5 th or 6 th postoperative day and patients experience pain only during the passage of stools. Corman et al., [4] comparing open and stapled techniques, did not find significant differences in the postoperative pain scores during all times of the day, except during defecation when the open group experienced severe pain as compared to the stapled group.


  Conclusions Top


Stapled hemorrhoidopexy was found to have less or no pain, when compared to the conventional open method and allowed early return to work. However, long-term complications are still unknown with most of the surgeons as they are still in the learning curve. It is to the treating surgeon to use his/her skill and acumen in selecting the procedure for treating his/her patients with hemorrhoids, which is suitable to the patient economically and curatively.

Our study confirms that stapled hemorrhoidopexy is associated with less postoperative pain, shorter duration of stay and is not associated with any greater morbidity than conventional techniques. The procedure is reproducible, and different surgeons can achieve comparable outcomes as long as they follow the basic principles and have a minimum of experience. The duration of surgery is a bit longer compared to the open technique in this study.

Long-term outcome is good; although in some cases, anorectal function can be somewhat compromised as is also true with conventional techniques. Stapled hemorrhoidopexy would seem to be the most suitable for reducible hemorrhoidal prolapse in that it repositions internal hemorrhoids and induces the regression of external hemorrhoids. It is as effective at curing symptoms as conventional techniques as long as the symptoms are directly related to the prolapse. According to the results of this study, we consider stapled hemorrhoidopexy as the preferred technique for hemorrhoids (especially Grade 4) given the appropriate indications and given the minimal duration of stay, can be done as a day-care procedure.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Goligher JC. Surgery of Anus, Rectum, Colon. 5 th ed. London: Bailliere Tindall; 1984. p. 98-149.  Back to cited text no. 1
    
2.
Ferguson JA, Heaton JR. Closed hemorrhoidectomy. Dis Colon Rectum 1959;2:176-9.  Back to cited text no. 2
    
3.
Longo A. Treatment of Haemorrhoids Disease by Reduction of Mucosa and Hemorrhoidal Prolapse with Circular Suturing Device: A New Procedure. Rome: 6 th World Congress of Endoscopic Surgery; 1998. p. 777-84.  Back to cited text no. 3
    
4.
Corman ML, Gravié JF, Hager T, Loudon MA, Mascagni D, Nyström PO, et al. Stapled haemorrhoidopexy: A consensus position paper by an international working party-Indications, contra-indications and technique. Colorectal Dis 2003;5:304-10.  Back to cited text no. 4
    
5.
Ganio E, Altomare DF, Gabrielli F, Milito G, Canuti S. Prospective randomized multicentre trial comparing stapled with open haemorrhoidectomy. Br J Surg 2001;88:669-74.  Back to cited text no. 5
    
6.
Mehigan BJ, Monson JR, Hartley JE. Stapling procedure for haemorrhoids versus Milligan-Morgan haemorrhoidectomy: Randomised controlled trial. Lancet 2000;355:782-5.  Back to cited text no. 6
    
7.
Rowsell M, Bello M, Hemingway DM. Circumferential mucosectomy (stapled haemorrhoidectomy) versus conventional haemorrhoidectomy: Randomised controlled trial. Lancet 2000;355:779-81.  Back to cited text no. 7
    
8.
Ho YH, Cheong WK, Tsang C, Ho J, Eu KW, Tang CL, et al. Stapled hemorrhoidectomy - Cost and effectiveness. Randomized, controlled trial including incontinence scoring, anorectal manometry, and endoanal ultrasound assessments at up to three months. Dis Colon Rectum 2000;43:1666-75.  Back to cited text no. 8
    
9.
Shalaby R, Desoky A. Randomized clinical trial of stapled versus Milligan-Morgan haemorrhoidectomy. Br J Surg 2001;88:1049-53.  Back to cited text no. 9
    
10.
Boccasanta P, Capretti PG, Venturi M, Cioffi U, De Simone M, Salamina G, et al. Randomised controlled trial between stapled circumferential mucosectomy and conventional circular hemorrhoidectomy in advanced hemorrhoids with external mucosal prolapse. Am J Surg 2001;182:64-8.  Back to cited text no. 10
    
11.
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;45:1437-44.  Back to cited text no. 11
    
12.
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;17:50-3.  Back to cited text no. 12
    
13.
Bikhchandani J, Agarwal PN, Kant R, Malik VK. Randomized controlled trial to compare the early and mid-term results of stapled versus open hemorrhoidectomy. Am J Surg 2005;189:56-60.  Back to cited text no. 13
    
14.
Gravié JF, Lehur PA, Huten N, Papillon M, Fantoli M, Descottes B, et al. Stapled hemorrhoidopexy versus Milligan-Morgan hemorrhoidectomy: A prospective, randomized, multicenter trial with 2-year postoperative follow up. Ann Surg 2005;242:29-35.  Back to cited text no. 14
    



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