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The New Zealand Medical Journal

 Journal of the New Zealand Medical Association, 08-October-2004, Vol 117 No 1203

Stapled haemorrhoidectomy—no pain, no gain?
Andrew Hill
Abstract
Stapled anopexy/haemorrhoidectomy (SH) was introduced in 1993 and first described by Longo in 1998. In New Zealand, more than 700 stapled haemorrhoidectomies have been performed. The procedure is one of the most studied of all recent new surgical technologies, and the literature is surveyed in this paper to assess the procedure’s safety and efficacy.
From review of the current literature is seems appropriate to conclude that SH is a safe procedure. It is probably not the answer for all haemorrhoids, especially those that are extremely large or are associated with a very significant external component. The procedure certainly has a sound theoretical basis and is likely here to stay. Patients like it because it is less painful than conventional techniques but they need to be counselled that its durability is not known.

Stapled anopexy/haemorrhoidectomy (SH) was introduced in 1993 and first described by Longo in 1998.1 In New Zealand, over 700 stapled haemorrhoidectomies have been performed and at the procedure’s 10th anniversary it seems timely to review the literature on this procedure. The literature is substantial and this procedure is one of the most studied of all recent new surgical technologies.
The rationale of SH is that haemorrhoids are a result of fragmentation of Park’s ligament; this results in submucosal tissue that lines the anal canal, along with the anal mucosa, sliding downwards. This prolapse obstructs venous outflow hence causing the clinical entity known as haemorrhoids.2 Hence the rationale of excising a ring of rectal mucosa, thereby reducing the mucosal prolapse. Thus the operation is perhaps better known as a stapled rectal mucosectomy.3 The operation has been given several other names including stapled anoplasty, stapled circumferential mucosectomy, Longo’s haemorrhoidectomy, stapled anopexy, stapled prolapsectomy, and stapled haemorrhoidopexy.4–9
Many studies have looked at the efficacy and safety of the procedure. Several disturbing cases of serious complications have also been reported. Overall, however, the procedure seems safe and well-tolerated, and appears to be effective—at least in the short term. Should New Zealand surgeons be performing this procedure? Certainly the procedure has proven popular with several surgeons in New Zealand but has yet to gain general acceptance. Several significant arguments have been raised against the use of the post partum haemorrhage (PPH) device. These arguments can be divided into four groups:
  • The first group of arguments concern the validity of the trials themselves.
  • The second group of arguments concern the safety of the procedure.
  • The third group of arguments concern the cost.
  • The fourth group of arguments concern the efficacy and durability of the procedure.

The validity of the trials

A significant issue has been the large number of patients accrued in the trials. Most colorectal surgeons only operate on a few haemorrhoid patients per year, as the majority of haemorrhoid patients can be dealt with in the outpatient clinic using rubber-band ligation or injection sclerotherapy.10 Thus, where do the trials get all their patients from? Are they operating on people that would be better dealt with by non-operative measures? A study from Singapore, which compared SH and rubber-band ligation for Grade III and small Grade IV haemorrhoids, supports this theory.11 Apart from studies from Singapore, the majority of the larger studies are multicentre. All other studies are relatively small.12,13

Is stapled haemorrhoidectomy safe?

Apart from a few isolated severe complications, the SH-operation complication rates are comparable to other conventional haemorrhoid (CH) operations.14–16 In a large multicentre study from Italy there was a complication rate of 15%. The commonest complications were severe pain and bleeding, each at 5% or less.17
Interestingly, in this study, 65% of complications occurred after the surgeon had done 25 or more cases—suggesting that the learning curve phenomenon does not apply. Septic complications in this study, and others, have been very rare. Bacteraemia after haemorrhoidectomy is more common with SH rather than after CH but this does not seem to have clinical relevance.18
Very little work has been done on anorectal physiology after SH. In a study (from the Middle East) it was shown that anorectal pressures were decreased after CH but not after SH—but this did not translate into clinical benefit.19 However, in Italian20 and UK21 studies, the differences in resting and squeeze pressures were not confirmed. Long-term follow-up will be important as with CH impairment of anal continence that the patient relates to the operation is as high as 29% at long-term follow-up.22
Despite the large amount of work done on efficacy and safety, the procedure has not been adopted widely in the United States or Canada with only a few reports coming from North America.23

Cost

The PPH instrument (from Ethicon Ltd) is expensive. SH is consistently faster to perform than CH, but this is unlikely to offset the cost of the instrument.19,24 No studies are available looking at costs, but this needs to be done if the operation is to be accepted universally.

Efficacy and durability

SH is at least as good as conventional haemorrhoidectomy and is less painful.25 Some have been skeptical—and in a recent paper from the UK studying a small group of patients, it was shown that while the SH is less painful, it was not associated with an earlier return to work than CH, and it failed to deal with external haemorrhoids.26
On the other hand, in the Middle East, a dramatic improvement in return to full activity was shown.19 Other studies have raised questions about the long-term results of the procedure despite the initial results being promising.6,13 In one study from the UK, good results have persisted up until 33 months.27

Conclusions

A recent systematic review from Australia has concluded that SH is probably at least as safe as CH.28 However they also concluded that the long-term outcome for the procedure has not been determined, and that studies of long-term outcome need to be performed before the procedure is adopted more widely.
What does the New Zealand general surgeon make of all of these data? Currently it can be justifiably concluded that SH is a safe procedure. It is probably not the answer for all haemorrhoids, especially those that are extremely large or are associated with a very significant external component. The procedure certainly has a sound theoretical basis and is probably here to stay. Patients like it because it is less painful than conventional techniques but they need to be counselled that its durability is not known.
Is this a case of ‘no pain–no gain’? Probably not. In our search for painless effective treatment for haemorrhoids (that are unresponsive to non-operative measures), this is one important step towards that goal.
Author information: Dr Andrew Hill, Senior Lecturer in Surgery, South Auckland Clinical School, Middlemore Hospital, University of Auckland, Auckland
Correspondence: Dr Andrew Hill, Senior Lecturer in Surgery, South Auckland Clinical School, Middlemore Hospital, University of Auckland, Auckland, PO Box 93311, Otahuhu, Auckland. Fax: (09) 267 9482; email: AHill@middlemore.co.nz
References:
  1. Longo A. Treatment of haemorrhoid disease by reduction of mucosa and haemorrhoidal prolapse with a circular stapling device: a new procedure. 6th World Congress of Endoscopic Surgery, Rome; 1998, p777–84.
  2. Thomson WHF. The nature of haemorrhoids. Br J Surg. 1975;62:542–52.
  3. Boccasanta P, Capretti PG, Venturi M, 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.
  4. Longo A. Stapled anopexy and stapled hemorrhoidectomy: two opposite concepts and procedures. Dis Col Rect. 2002;45:571–2.
  5. Correa-Rovelo JM, Tellez O, Obregon L, et al. Stapled rectal mucosectomy vs. closed hemorrhoidectomy: a randomized, clinical trial. Dis Col Rect. 2002;45:1367–74.
  6. Ortiz H, Marzo J, Armendariz P. Randomized clinical trial of stapled haemorrhoidopexy versus conventional diathermy haemorrhoidectomy. Br J Surg. 2002;89:1376–81.
  7. Lloyd D, Ho KS, Seow-Choen F. Modified Longo's hemorrhoidectomy. Dis Col Rect. 2002;45:416–7.
  8. Orrom W, Hayashi A, Rusnak C, Kelly J. Initial experience with stapled anoplasty in the operative management of prolapsing hemorrhoids and mucosal rectal prolapse. Am J Surg. 2002;183:519–24.
  9. Pernice LM. The author replies. Dis Col Rect. 2002;45:572.
  10. MacRae HM, McLeod RS. Comparison of hemorrhoidal treatment modalities. Dis Col Rect. 1995;38:687–94.
  11. Peng BC, Jayne DG, Ho YH. Randomized trial of rubber band ligation vs. stapled hemorrhoidectomy for prolapsed piles. Dis Col Rect. 2003;46:291–7.
  12. Pavlidis T, Papaziogas B, Souparis A, et al. Modern stapled Longo procedure v. conventional Milligan-Morgan hemorrhoidectomy: a randomized controlled trial. Int J Colorect Dis. 2002;17:50–3.
  13. Goulimaris I, Kanellos I, Christoforidis E, et al. Stapled haemorrhoidectomy compared with Milligan-Morgan excision for the treatment of prolapsing haemorrhoids: a prospective study. Eur J Surg. 2002;168:621–5.
  14. Maw A, Eu KW, Seow-Choen F. Retroperitoneal sepsis complicating stapled hemorrhoidectomy: report of a case and review of the literature. Dis Col Rect. 2002;45:826–8.
  15. Wong LY, Jiang JK, Chang SC, Lin JK. Rectal perforation: a life threatening complication of stapled hemorrhoidectomy: report of a case. Dis Col Rect. 2003;46:116–7.
  16. Pescatori M. PPH stapled hemorrhoidectomy--a cautionary note.[comment]. Dis Col Rect. 2003;46:131.
  17. Ravo B, Amato A, Bianco V, et al. Complications after stapled hemorrhoidectomy: can they be prevented? Tech Coloproctol 2002;6:83–8.
  18. Maw A, Concepcion R, Eu KW, et al. Prospective randomized study of bacteraemia in diathermy and stapled haemorrhoidectomy. Br J Surg. 2003;90:222–6.
  19. Shalaby R, Desoky A. Randomized clinical trial of stapled versus Milligan-Morgan haemorrhoidectomy. Br J Surg. 2001;88:1049–53.
  20. Ganio E, Altomare DF, Gabrielli F, et al. Prospective randomized multicentre trial comparing stapled with open haemorrhoidectomy. Br J Surg. 2001;88:669–74.
  21. Wilson MS, Pope V, Doran HE, et al. Objective comparison of stapled anopexy and open hemorrhoidectomy: a randomized, controlled trial. Dis Col Rect. 2002;45:1437–44.
  22. Johannsson HO, Graf W, Pahlman L. Long-term results of haemorrhoidectomy. Eur J Surg. 2002;168:485–9.
  23. Singer MA, Cintron JR, Fleshman JW, et al. Early experience with stapled hemorrhoidectomy in the United States. Dis Col Rect. 2002;45:367–9.
  24. Palimento D, Picchio M, Attanasio U, et al. Stapled and open hemorrhoidectomy: randomized controlled trial of early results. World J Surg 2003;27:203–7.
  25. Kairaluoma M, Nuorva K, Kellokumpu I. Day-case stapled (circular) vs. diathermy hemorrhoidectomy: a randomized, controlled trial evaluating surgical and functional outcome. Dis Col Rect. 2003;46:93–9.
  26. Cheetham MJ, Cohen CR, Kamm MA, Phillips RK. A randomized, controlled trial of diathermy hemorrhoidectomy vs. stapled hemorrhoidectomy in an intended day-care setting with longer-term follow-up. Dis Col Rect. 2003;46:491–7.
  27. Smyth EF, Baker RP, Wilken BJ, et al. Stapled versus excision haemorrhoidectomy: long-term follow up of a randomised controlled trial. Lancet. 2003;361:1437–8.
  28. Sutherland LM, Burchard AK, Matsuda K, et al. A systematic review of stapled hemorrhoidectomy. Arch Surg 2002;137:1395–1406.


     
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