|Year : 2020 | Volume
| Issue : 2 | Page : 82-85
Stapled hemorrhoidopexy: A single-center 8 years' experience
Rishi Kumar Agrawal1, Priti Agrawal2, Jyotirmay Chandrakar3
1 Department of General and Laparoscopic Surgery, Aarogya Hospital and Test Tube Baby Center, Raipur, Chhattisgarh, India
2 Department of Obstetrics, Gynecology and Infertility, Aarogya Hospital and Test Tube Center, Raipur, Chhattisgarh, India
3 Department of Anesthesia, Aarogya Hospital and Test Tube Center, Raipur, Chhattisgarh, India
|Date of Submission||12-Sep-2020|
|Date of Acceptance||21-Jan-2021|
|Date of Web Publication||24-Feb-2021|
Dr. Rishi Kumar Agrawal
Department of General and Laparoscopic Surgery, Aarogya Hospital and Test Tube Baby Center Raipur, Opposite Gold Gym, Shankar Nagar, Raipur - 492 006, Chhattisgarh
Source of Support: None, Conflict of Interest: None
Purpose: Stapled hemorrhoidopexy (SH) is associated with shorter operative time, reduced inpatient stay, less pain, and earlier return to normal activities. The present study was conducted to assess the clinical consequences of SH and to establish the suitability of SH for all patients of grade III or IV hemorrhoids.
Patients and Methods: This study included 250 patients who underwent SH at Aarogya Hospital, Raipur, India, from January 1, 2012 to December 31, 2017 and follow-up completed on December 31, 2019. SH procedure was performed according to the LONGO technique. The pain was assessed using a visual analog scale (VAS). Patients were followed up after 1 week, then monthly for 2 months, and 6 monthly for 2 years.
Results: There were 163 males (65.2%) and 87 (34.8) females. Preoperatively, 87.2% of cases had anal bleeding, constipation in 73.2% cases, and associated pain in 52.4% cases. Operative time duration ranged between 25 and 50 min. Two-hundred and twenty-one (88.4%) patients were discharged within 24 h postoperatively and remaining within 48 h.
Discussion: The most important advantage of SH as cited by various studies is a profound reduction in postoperative pain analgesia requirement and better quality of life. The postoperative pain rapidly decreased in severity to the VAS score of 2, in 73.6 cases within 24 h, facilitating early discharge of the patients our recurrence rates were nil in SH.
Conclusion: Our study demonstrates that SH is a safe, effective, and well-tolerated procedure with minimum postoperative pain and complication rates.
Keywords: Hemorrhoids, open hemorrhoidectomy, pain, stapled hemorrhoidopexy, visual analog scale
|How to cite this article:|
Agrawal RK, Agrawal P, Chandrakar J. Stapled hemorrhoidopexy: A single-center 8 years' experience. Saudi Surg J 2020;8:82-5
| Introduction|| |
Hemorrhoids are among the most frequent anorectal conditions affecting 4%–36% of the general population. A large number of patients who have hemorrhoids are asymptomatic. Bleeding during defecation is the most frequent presenting symptom. The hemorrhoids may prolapse (Grades II–IV) and result in other symptoms of mucus seepage, pruritus, loss of discrimination and continence to flatus, and occasional fecal incontinence. Pain is not a usual accompaniment of hemorrhoids, but thrombosed hemorrhoids become painful.
Surgical interventions are usually required for grades III and IV hemorrhoids. Excision of all hemorrhoidal tissue with somatic enervation is achieved with conventional hemorrhoidectomy, either with an open technique as described by Milligan and Morgan, in 1937 or in a closed manner, as described by Ferguson et al. in 1959.
Despite low complication rates and high efficacy for long-lasting symptomatic control, severe pain may arise postoperatively due to manipulation and removal of innervated anoderm below the dentate line and leading cause for deferral of treatment. Aiming to reduce postoperative pain, LONGO in 1998, proposed a stapled procedure as a radical alternative for the surgical treatment of prolapsing hemorrhoids. The goal of this new form of operative approach is not to excise hemorrhoids but to replace prolapsed anorectal mucosa in its original anatomical position by means of removing and stapling redundant mucosa and thus decreasing hemorrhoidal vessels load flow. Less postoperative pain is expected since there is no perianal wound and the rectal wall above the dentate line has no somatic endings; stapled hemorrhoidopexy (SH) is associated with shorter operative time, reduced inpatient stay, less pain, and earlier return to normal activities.
The present study was conducted to assess the clinical consequences of SH and to establish the suitability of SH for all patients of grade III or IV hemorrhoids.
| Patients And Methods|| |
This study included 250 patients who underwent SH at Aarogya Hospital and Test Tube Baby Center, Raipur, India, from January 1, 2012 to December 31, 2017 and follow-up completed on December 31, 2019. SH was performed by one dedicated surgical team.
The inclusion criteria were age between 25 and 75 years, symptomatic Grades III and IV degree hemorrhoids, and fitness for anesthesia under the American Society of Anesthesiologists grades I and II.
Exclusion criteria were thrombosed hemorrhoids, concomitant perianal fistula, fissures or abscesses, proposed second procedure under same anesthesia, and unwillingness of the patient to undergo SH over conventional methods. Preoperative evaluation included general physical and complete proctological examinations (including anorectoscopy or rectosigmoidoscopy) as well as routine laboratory tests. Patients were advised to take laxative on the night before surgery and were admitted to the hospital on the day of surgery.
Intravenous ceftriaxone injection 1 g and metronidazole 500 mg were given half hour before induction of anesthesia. All cases were done under spinal anesthesia.
SH procedure was performed according to the LONGO technique. All patients were operated on in the lithotomy position. Stay sutures with 2-0 silk were applied at 3, 6, 9, and 12 o' clock. An anal ring was applied and fixed to the anal verge by the previously taken stay sutures. The inner end of the ring was beyond the dentate line.
Purse-string sutures were taken all around the anal mucosa on top of hemorrhoids, followed by a per-rectal examination to make sure that the muscle layer is not taken within the sutures so as to avoid postoperative anal stenosis. Similarly, in female patients, per-vaginal examination was done to ensure that the vaginal wall was not taken within the suture. A specialized circular stapler (pph 033 Ethicon endosurgery or Kangdi Hemorrhoid Circular Stapler) was introduced into the anal canal and the two ends of the purse-string sutures were passed through special holes in the stapler and tied. The stapler was then tightened and fired. The stapler was kept closed in place compressing for 30 s in order to encourage hemostasis. The staple line was then checked for bleeding points and if required, further hemostasis was attained using bipolar coagulation and in some cases, hemostatic sutures using chronic catgut 2-0. Large external skin tags if present were cut with monopolar cautery. Finally, diclofenac and tramadol suppository were kept and gentle anal packing was done. The pack was removed after 12 h.
The pain was assessed using a visual analog scale (VAS), 0 indicated no pain and 10 indicated maximum pain. Pain scores were evaluated at 6 h, 12 h, and before discharge. Patients were routinely discharged after 24 h of surgery and were kept up to 48 h in cases of comorbidities such as hypertension and diabetes mellitus. At the time of discharge, patients were given lactulose (15 ml daily), oral antibiotics, and analgesics if required. Patients were asked to report immediately to the hospital if there was any excessive bleeding per rectum, fever, or constipation (unable to pass motion for more than 3 days).
Patients were followed up after 1 week, then monthly for 2 months, and 6 monthly for 2 years. Patient data on operative time, hospital stay, and postoperative analgesic requirements and complications such as perianal pain, bleeding, persistent prolapse, and patients' satisfaction were actively noted during follow-up.
| Results|| |
A total of 250 patients between the age of 25 and 75 years were included. The mean age was 45.6 ± 12.71 years. There were 163 males (65.2%) and 87 (34.8) females [Table 1]. Preoperatively, 87.2% cases had anal bleeding, constipation in 73.2% cases, and associated pain in 52.4% cases [Table 2]. All cases were done under spinal anesthesia and operative time duration ranged between 25 and 50 min (average 30 min). Operating time was prolonged if bleeding occurred from the stapling line. 221 (88.4%) patients were discharged within 24 h postoperatively and remaining within 48 h.
Postoperative pain was evaluated, 76% of patients have severe pain after 6 h of surgery and 73.6% cases had only mild pain after 24 h [Table 3]. 95% of cases were given single dose of 75 mg intravenous diclofenac 8 h postoperatively. Complications such as perianal pain, bleeding, persistent prolapse, and patient's satisfaction were actively noted during follow-up. All patients were advised to take paracetamol 650 mg tablets if pain occurred. 50% had to take only two tablets within 7 days postoperatively for pain relief.
Postoperatively, tenesmus occurred in 2% of cases. In two cases, the staple pin was retained even after 2 months of surgery, was removed by gentle pulling with artery forceps under proctoscopic guidance [Table 4]. All patients have completed follow-up of 2 years. 98% of cases are satisfied with the procedure [Table 5].
| Discussion|| |
Hemorrhoids are equally distributed in men and women and the incidence increases with age. Our study group included 65.2% males almost double to females. Similar male preponderance was shown by Garg et al.
The most important advantage of SH as cited by various studies is a profound reduction in postoperative pain analgesia requirement and better quality of life. The most important disadvantage of conventional hemorrhoidectomy is postoperative pain. In series of SH by Bota et al., the median number of dose for pain control was 1.43 (range 0–5 dose and in our series 95% of patients had adequate pain relief with single dose of diclofenac.
The postoperative pain rapidly decreased in severity to the VAS score of 2, in 73.6 cases within 24 h, facilitating early discharge of the patients. Garg et al. also reported similar declining VAS scores and improved quality of life.
Nahas et al. reported no perianal or suture infection in their series. Anal stenosis occurred in their two cases. In our series, retained staple pin occurred in 2 cases (0.8%) which no authors have encountered. Stenosis at suture line occurred in one case (0.4%) Riza et al. reported rectal stenosis which was due to high staple line (i.e., above 4 cm) and they suggested that SH through a simple procedure, the application of purse-string suture is a critical step. The staple line should be between 3 and 3.5 cm to prevent these complications.
Our recurrence rates were nil in SH for the operated site, only in two cases external piles occurred which were treated conservatively. Araujo et al. compared late outcomes of SH with SH + excisional hemorrhoidectomy and concluded that combining SH and closed excisional procedure for prolapse is a highly efficient procedure for more advanced hemorrhoid disease.
Tenesmus occurred in 4% of cases, whereas Ortiz et al. reported in 40% of cases and suggested that conventional diathermy should be recommended in patients with symptomatic, prolapsed, and irreducible piles.
Long-term complications with SH are still uncertain. Shalaby and Despky reported that after 1 year of follow-up, there was 1% rate of prolapse incurrence, 2% of anal stenosis, and 3% of perianal thrombosis in the stapled patients compared with 2% recurrence rate, 5% anal stenosis, and 3% anal thrombosis in the conventional excised group.
George et al. found SH most suitable for reducible hemorrhoidal prolapse in that it repositions internal hemorrhoids and induces the regression of external hemorrhoids.
Our patient satisfaction rate was 98% which is comparable to Riaz et al. and George et al.
| Conclusion|| |
Our study demonstrates that SH is a safe, effective, and well-tolerated procedure with minimum postoperative pain and complication rates, thereby attributing high patient's satisfaction rates. Most of the patients are discharged within 24 h and so this is our procedure of choice for all symptomatic grades III and IV hemorrhoids.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Milligan ET, Morgan CN. Surgical anatomy of the anal canal and operative treatment of hemorrhoids. Lancet 1937;2:1119-24.
Ferguson JA, Mazier WP, Ganchrow MI, Friend WG. The closed technique of hemorrhoidectomy. Surgery 1971;70:480-4.
Longo A. Treatment of Hemorrhoids Disease by Reduction of Mucosa and Hemorrhoidal Prolapse with a Circular Suturing Device: A New Procedure: Proceedings of the 6th
World Congress of Endoscopic Surgery, Rome, Italy; 1998.
Garg PK, Kumar G, Jain BK, Mohanty D, Quality of life after stapled hemorrhoidopexy: A prospective observational study. BioMed Res Int 2013;2013:903271.
Bota R, Ahmed M, Aziz A. Is stapled hemorrhoidectomy a safe procedure for third and fourth grade hemorrhoids? An experience at Civil Hospital Karachi. Indian J Surg 2015;77:1057-60.
Nahas SC, Borba MR, Brochado MC, Marques CF, Nahas CS, Neto BM. Stapled hemorrhoidectomy for the treatment of haemorrhoids. Arq Gastroenterol 2003;40:35-9.
Riaz AA, Singh A Patel A, Ali A, Livingstone JI. Stapled haemorrhoidectomy. A day case procedure for symptomatic haemorhroids. BJMP 2008;1:23-7.
Araujo SE, Horcel LD, Seid VE, Bertoncini AB, Klajner S. Long term results after stapled hemorrhoidopexy alone and complemented by excisional hemorrhoridectomy: A retrospective cohort study. Arq Bras Cir Dig 2016;29:159-63.
Ortiz H, Marzo J, Armendariz P, Mignel MD. Stapled hemorrhoidopexy vs dialthermy excision for fourth degree hemorrhoids: A randomized, clinical trial and review of literature. Dis Colon Rectum 2005;48:809-15.
Shalaby R, Despky A. Randomized clinical; trial of Stapled versus Milligan-Morgan haemorrhoidectomy. Br J Surg 2001;88:1049-53.
George R, Vivek S, Suprej K. How long to stay in hospital: Stapled versus open hemorrhoidectomy ? Saudi Surg J 2016;4:108-12. [Full text]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]