Journal of the New Zealand Medical Association, 08-October-2004, Vol 117 No 1203
Stapled haemorrhoidectomy—no pain, no gain?
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 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
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
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
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