Stapled Hemorrhoidopexy; Outcome Assessment

Thomas Mazza MD, Scott D. Goldstein MD, Gerald Isenberg MD, James Fitzgerald MD, Andrew Richards MD*, Brian Delong MD*, Larry Sollenberger MD*
Introduction
Hemorrhoids have long been a problem in healthcare affecting more than 1 million Americans per year. It has been estimated that over a 3 year period approximately 4.4% of the US population will have symptoms attributed to hemorrhoids. Treatments for hemorrhoids vary from lifestyle modifications to topical therapy to surgical excision. Recently a new approach to treatment has entered the surgical realm; the so-called procedure for prolapsed hemorrhoids (PPH).

*
Discussion

Community Practice Outcomes

We provide a retrospective analysis of the experience with PPH during a 3 year period in a 3 physician private colorectal practice and a 1 year period in an academic training program for colon and rectal surgery Chart review identified 7 procedures completed in 2002, 43 in 2003, and 88 in 2004. Another 14 procedures were completed during the 2005-2006 academic 30 year (n=152). Indications for surgery included: 25 Prolapse grade II or III: 152 Bleeding: 129 20 Discomfort: 47 15 Anal hygiene: 19 Male to Female ratio: 78 : 74
10

Retrospective survey of patients experiences

Total of 78 patients contacted for survey
Degree of pain post operatively
Post Op pain assessment

Age Distribution

50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0%

Male

Female

Anatomy Overview
Vascular cushions Help protect anal canal during defecation Blood supplied primarily from superior hemorrhoidal artery Usual bundles located in three distinct areas Increased intraabdominal pressure may cause backflow of venous blood

Extreme: 12.8% (n=10) Moderate: 38.5% (30) Little: 35. 9% (28) None: 12.8% (10)
Pain comparison to expectations

Pitfalls of study Retrospective survey of patient population No comparison group No good long term follow up to assess durability Survey addresses only subjective data Other procedures may have influenced outcomes assessment

Conclusion
Hemorrhoids have been and will continue to be a prominent healthcare issue for the American population. Stapled hemorrhoidectomy is a new innovation in the treatment of prolapsing hemorrhoid disease which provides patients with a less painful means of relief, allows quicker return to normal function, and provides a high degree of post operative satisfaction. Economically, the procedure requires less operative time and infrequently necessitates hospitalization. The stapler, however, is costly and is not reusable. The technique is still relatively new, and reliable randomized, controlled trials to date are small without good long term results for assessing durability.
53%

No ne

Li tt le

at e

Age distribution Males Range: 28-76 yrs 20-29: 1 30-39: 8 40-49: 28 50-59: 21 60-69: 13 70-79: 7 Mean: 52.1 y/o Females Range: 23-86 yrs 20-29: 2 30-39: 8 40-49: 27 50-59: 11 60-69: 10 70-79: 13 >80: 3 Mean: 54.2 y/o

M od er

5 0

203340506070- >80 29yrs 39yrs 49yrs 59yrs 69yrs 79yrs

Type of anesthesia General: 19 Monitored sedation: 131 Associated procedures during PPH Colonoscopy: 34 Removal of skin tag: 29 External hemorrhoidectomy: 4 Lateral sphincterotomy: 3 Ferguson Hemorrhoidectomy: 1

Status of symptoms

Less than expected: 67.9% (53) More than expected: 11.5% (9) As expected: 20.5% (16) Completely resolved: 52.6% (41) Significant improvement: 38.5% (30) Little improvement: 6.4% (5) Recurrent symptoms: 2.6% (2)

Status of Symptoms
6% 3%

38%

Ex

tr e

m e

Review of Literature
Completely resolved Significant Improvement Little Improvement Recurrence

View from prone position

Stapled Hemorrhoidopexy
Initially introduced by Longo in 1998 by modifying EEA stapling technique used in rectal surgery Utilizes a 33mm circular stapler passed via the anal canal Essentially lifts or repositions the anal canal tissue Procedure generally performed in about 30-45 minutes Remaining internal hemorrhoid tissues shrinks within 4 to 6 weeks

Delayed procedures External hemorrhoidectomy: Control of bleeding: 4 Ferguson hemorrhoidectomy for recurrence: 3 Removal of skin tag: 2 Type of hospital visit 2 Banding: Out patient: 133 Lateral sphincterotomy: Same day admission: 11 Dilation: 1 Follow up In patient: 8 Complications Bleeding: 33 Unexpected admission: 6 Urinary retention: 5 Impaction: 3 Abscess: 2
Post op visits (13 patients lost to follow up) Range: 0-11 Average: 1.6 visits Mean time to discharge: 10.8 wks Discharge Mode: 1 visit 3 wks post op
Anesthesia
88% 12%

Patients Subjective Outcome

Average length of time to return to normal function

70% 60% 50% 40% 30% 20% 10% 0%

ns at i Ex ce lle nt sf ie d fie d Sa tis G oo d

<1 week: 50% (39) 1-2 weeks: 23.1% (18) 2-3 weeks: 15.4% (12) >3 weeks: 11.5% (9)
Degree of satisfaction with procedure Excellent: 64.1% (50) Good: 21.8% (17) Satisfied: 7.7% (6) Unsatisfied: 6.4% (5)
Would recommend procedure to family or friends with similar symptoms. Yes: 89.7% (70) No: 2.6% (2 ) Undecided: 7.7% (6)

European study of 1077 patients concluded that patients who had PPH had less pain, shorter hospital stays, shorter operative time, quicker return to normal activity and no difference in quality of life scores. They did however have a higher recurrence rate.* A similar US study of 117 patients concluded PPH offers benefits of less post operative pain, less analgesic requirements, and less pain at first bowel movement, while providing similar control of symptoms.**
A French study compared stapled hemorrhoidopexy verses Milligan-Morgan with 2 year follow up. A series of 134 patients in 7 centers were evaluated preoperatively and 6 weeks, 1 year and 2 years post treatment. They concluded PPH caused less pain, achieved comparable outcomes and was equally effective in relieving symptoms.
*Stapled Hemorrhoidopexy Compared With Conventional Hemorrhoidectomy: Systematic Review of Randomized, Controlled Trials. Pasha J. Nisar1, et.al. Diseases of the Colon & Rectum Vol.47 No. 11 **A Prospective, Randomized, Controlled Multicenter Trial Comparing Stapled Hemorrhoidopexy and Ferguson Hemorrhoidectomy: Perioperative and One-Year Results. A. J. Senagore, et.al. Diseases of the Colon & Rectum Vol. 47, No. 11 Stapled Hemorrhoidopexy Versus Milligan-Morgan Hemorrhoidectomy: A Prospective, Randomized, Multicenter Trial With 2-Year Postoperative Follow Up. Gravi, Jean Franois MD, et.al. Annals of Surgery. 242(1):29-35, July 2005.

General MAC