Stapled and Open Hemorrhoidectomy: Randomized Controlled Trial of Early Results

Abstract

The aim of the study was to compare the early results in 52 patients randomly allocated to undergo either stapled or open hemorrhoidectomy. Seventy‐four patients with grade III and IV hemorrhoids were randomly allocated to undergo either stapled (37 patients) or open (37 patients) hemorrhoidectomy. Stapled hemorrhoidectomy was performed with the use of a circular stapling device. Open hemorrhoidectomy was accomplished according to the Milligan‐Morgan technique. Postoperative pain was assessed by means of a visual analogue scale (V.A.S.). Recovery evaluation included return to pain‐free defecation and normal activities. A 6‐month clinical follow‐up and a 17.5 (10 to 27)‐month median telephone follow‐up was obtained in all patients. Operation time for stapled hemorrhoidectomy was shorter (median 25 [range 15 to 49] minutes versus 30 [range 20 to 44] minutes, p = 0.041). Median (range) V.A.S. scores in the stapled group were significantly lower (V.A.S. score after 4 hours: 4 [2 to 6] versus 5 [2 to 8], p = 0.001; V.A.S. score after 24 hours: 3 [1 to 6] versus 5 [3 to 7], p = 0.000; V.A.S. score after first defecation: 5 [3 to 8] versus 7 [3 to 9], p = 0.000). Resumption of pain‐free defecation was significantly faster in the stapled group (10 [6 to 14] days vs 12 [9 to 19] days, p = 0.001). At follow‐up 4 weeks and 6 months postoperatively the median (range) symptom severity score was similar in both groups (1 [0 to 2] versus 0 [0 to 3], p = 0.150 and 0 [0 to 2] versus 0 [0 to 2], p = 0.731). At long‐term follow‐up occasional pain was present in 6/37 (16.2) patients in the stapled group and 7/37 (18.9%) in the Milligan‐Morgan group (p = 1.000); episodes of bleeding were reported by 8/37 (21.6%) patients in the stapled group and 5/37 (13.5%) patients in the Milligan‐Morgan group (p = 0.542). No problems related to continence and defecation were reported in either group. Patients were satisfied with the operation in 33/37 (89.2%) cases in the stapled group and 31/37 (83.8%) cases in the Milligan‐Morgan group (p = 0.735). Hemorrhoidectomy with a circular staple device is easy to perform and achieves better results than the Milligan‐Morgan technique in terms of postoperative pain and recovery. Comparable results are obtained at long‐term follow‐up.

Systematic review and meta-analysis of randomized controlled trials comparing stapled haemorrhoidopexy with conventional haemorrhoidectomy

“…haemorrhoidopexy as a day-case procedure 27,32 . General anaesthesia was used in ten trials 24,25,27 -30,32,33,35,37 , spinal anaesthesia in five 23,36,39,40,43 , spinal or general anaesthesia in seven 16,17,21,34,38,41,42 , local anaesthesia in one 22 , and local or general or saddle anaesthesia in one 31 . The type of anaesthesia not stated in five trials 15,18,19,20,26 .…”

“…Hetzer et al 16 Gravie et al 20 Boccasanta et al 17 Palimento et al 40 Correa-Rovelo et al 41 Ganio et al 21 Shalaby and Desoky 24 Racalbuto et al 31 Lau et al 25 Kraemer et al 42 Cheetham et al 27 Kairaluoma et al 32 Peng et al 33 Senagore et al 22 Ortiz et al 43 Chung et al 34 Ho et al 35 Wilson et al 19 Bikhchandani et al 36 Khalil et al 37 Basdanis et al 38 Not estimable (95 per cent c.i. 1·19 to 5·32); P = 0·016).…”

DG-RAR for the treatment of symptomatic grade III and grade IV haemorrhoids: a 12-month multi-centre, prospective observational study

“…In a meta-analysis [13], the RR for prolapse following CH is reported to be 4 %. However, both treatment options can be associated with extensive post-operative pain [5], faecal incontinence and anal stenosis [3]. Nonetheless, for most authors CH remains the standard treatment for advanced piles, because novel techniques including SH do not show the same effectiveness.…”

“…Despite excellent long-term results, CH is associated with significant side effects and complications. In addition to excessive post-operative pain, symptoms of incontinence and anal stenosis have been described in considerable numbers [2–5]. For SH, results are more convenient concerning post-operative pain.…”

“…For SH, results are more convenient concerning post-operative pain. However, reoperations have been reported in up to 10 % of patients [5, 6] and, albeit very rare, this technique can be associated with severe septic complications [5, 7]. …”