Evaluation of post-operative complications after Milligan- Morgan haemorrhoidectomy versus Stapled Haemorrhoidopexy techniques

Background Haemorrhoidal disease is one of the oldest illnesses known to mankind. It leads to significant pain, discomfort and poor quality of life. It is one of the common diseases which affect mankind but it is difficult to give an accurate figure of the prevalence because although many patients present with symptoms, many do not and some never bring it to notice of clinicians. The word hemorrhoids means flow of blood, the word pile means a ball, indicating two cardinal symptoms of this disease; bleeding per rectum and mass per anus. Aim of the work Aim of the work is to detect and compare the post-operative complications (Pain, Bleeding and anal stenosis) after 2 of the most commonly used techniques for management of the clinically diagnosed third and fourth stage hemorrhoids: Milligan-Morgan hemorrhoidectomy and stapler hemorrhoidopexy. Patient and Methods After obtaining approval from The College Ethical Committee, the study entitled "Evaluation of Postoperative Complications after Open MM Hemorrhidectomy versus Stapled Hemorrhoidopexy" was conducted on a total of 30 patients with hemorrhoids undergoing either conventional hemorrhoidectomy by Milligan Morgan (MM) technique or stapler hemorrhoidopexy. The patients were selected randomly after fulfilling the inclusion criteria in the department of general surgery, Ain Shams University hospitals over a period of 4 months starting from 1 August 2019 to 1 December 2019. Patients were admitted via surgical outpatient clinic. Patients were randomly distributed to 2 groups (A & B), each group containing 15 patients. Results A total of 30 patients who underwent either conventional hemorrhoidectomy (CH) or stapler hemorrhoidopexy (SH) in The Department of Surgery, Faculty of Medicine, Ain Shams University included in this study for 4 months started from 1/8/2019 and ended in 1/12/2019 and the following results are obtained. Conclusion Haemorrhoidal disease is considered as one of the commonest ano-rectal diseases. Non-surgical measures whatever drug therapy or office procedures, can be presented to the patients with stage 1 and stage 2 haemorrhoids. However, when these measures fail, surgical intervention must be thought for the patients with stage 3 and stage 4 haemorrhoids. Surgical intervention should be tailored to each patient in accordance to the seriousness of symptoms, the magnitude of the external anorectal element and the presence of any concurrent ano-rectal morbidity. At present, there are many surgical interventions obtainable for treatment of prolapsing piles disease and most of them yielding acceptable success rates. Conventional Haemorrhoidectomy (CH) whatever open (Milligan Morgan) or closed (Ferguson) is considered the gold standard for surgical intervention of piles but due to the severe associated post-operative pain, especially with defecation, Stapled Haemorrhoidopexy (SH) seems to present shorter operative time, less post-operative pain, less bleeding and anal stricture and also less time off work in comparison with CH. Although rare but horrible complications have been noted with SH, which dictate that SH should be performed only by experienced surgeons. Eventually we strongly recommend the use of stapler devices for haemorrhoidectomy when and where possible especially for high grade and prolapsing haemorrhoids although more research and study should be made in this concern for more confirmation of our results due to decreased specimen size and short post-operative follow up period in our study.

969 Intra-Abdominal Rectal Perforation Post Haemorrhoidal Artery Ligation Operation (HALO) And Converted Ligasure Open Haemorrhoidectomy

Case Report Symptomatic prolapsing haemorrhoids are usually treated with either haemorrhoidal artery ligation operation (HALO), stapled haemorrhoidopexy or open haemorrhoidectomy. Complications are rare with serious complications like rectal perforation reported scarcely in literature. We report a case of intraperitoneal rectal perforation following transanal haemorrhoidal artery ligation and converted open Ligasure-assisted haemorrhoidectomy in a 74-year-old lady with background portal hypertension secondary to primary biliary cirrhosis. We present this case to highlight the importance of preoperative medical optimisation of portal hypertension prior to surgical intervention and consideration of primary open techniques in grade 4 haemorrhoid surgery.

Redo stapled haemorrhoidopexy: our experience at max hospital, Gurugram

Stapled haemorrhoidopexy like any other surgical procedure can also fail due to error by surgeons or machine, the stapler. Experience of the surgeon plays the most important role in avoiding recurrence of haemorrhoid after stapled haemorrhoidopexy. A description of operative technique and patient’s demographics are presented. Ten cases of recurrence of haemorrhoid after stapled haemorrhoidopexy done elsewhere were managed by redo haemorrhoidopexy between 1st June 2011-1st June 2020 at Max hospital, Gurugram, Haryana. All cases were successfully operated though the reason of recurrence was different in these cases. Haemorrhoids or piles are common surgical problem a surgeon faces. The first known mention of this disease is from a 1700 BC Egyptian Papyrus. Stapled haemorrhoidopexy is a new and successful technique to treat haemorrhoids, was developed by Dr. Antonio Longo, Italian surgeon, in 1998.Stapled haemorrhoidopexy avoids formation of wound in the operative area, has the advantage of significantly reducing the post-operative pain. Inadequate knowledge and experience, over confidence, wrong patient selection, improper fixation of circular anal dilator, purse string at wrong site, are common causes of recurrence. We managed the recurrence with taking care of causative factors while doing redo-stapled haemorrhoidopexy successfully in all cases. No case of recurrence of haemorrhoids after stapled haemorrhoidopexy was considered for conventional haemorrhoidectomy. All cases were done with redo-haemorrhoidopexy.

A systematic review of the literature assessing the outcomes of stapled haemorrhoidopexy versus open haemorrhoidectomy

Background Symptomatic haemorrhoids affect a large number of patients throughout the world. The aim of this systematic review was to compare the surgical outcomes of stapled haemorrhoidopexy (SH) versus open haemorrhoidectomy (OH) over a 20-year period. Methods Randomized controlled trials published between January 1998 and January 2019 were extracted from Pubmed using defined search criteria. Study characteristics and outcomes in the form of short-term and long-term complications of the two techniques were analyzed. Any changes in trend of outcomes over time were assessed by comparing article groups 1998–2008 and 2009–2019. Results Twenty-nine and 9 relevant articles were extracted for the 1998–2008 (period 1) and 2009–2019 (period 2) cohorts, respectively. Over the two time periods, SH was found to be a safe procedure, associated with statistically reduced operative time (in 13/21 studies during period 1 and in 3/8 studies during period 2), statistically less intraoperative bleeding (3/7 studies in period 1 and 1/1 study in period 2) and consistently less early postoperative pain on the visual analogue scale (12/15 studies in period 1 and 4/5 studies in period 2) resulting in shorter hospital stay (12/20 studies in period 1 and 2/2 studies in period 2) at the expense of a higher cost. In the longer term, although chronic pain in SH and OH patents is comparable, patient satisfaction with SH may decline with time and at 2-year follow-up OH appeared to be associated with greater patient satisfaction. Conclusions SH appears to be safe with potential advantages, at least in the short term, but the evidence is lacking at the moment to suggest its routine use in clinical practice.

Evaluation of outcome in open and stapler haemorrhoidectomy in grade III/IV haemorrhoids

Background: Haemorrhoids are one of most common benign anorectal malformation worldwide. There are various surgical treatment modalities for 3rd and 4th degree haemorrhoids. Open haemorrhoidectomy was the most widely practiced and is considered the current gold standard. In search of a newer surgical technique, stapler has been introduced for haemorrhoidectomy and has revolutionised operative procedures over the last decade world-wide due to its ease and simplicity and lesser post-operative complications. The following study was done to evaluate the outcome of open versus stapled haemorrhoidectomy in terms of post-operative pain, postoperative bleeding, duration of surgery, duration of hospital stays in a medical college hospital at Raipur, Chhattisgarh.Methods: This was a prospective follow-up study, in patients undergoing surgery for grade III/IV haemorrhoids conducted in the Department of Surgery, Dr BRAM Hospital, Raipur, from August 2017 to July 2018. Fourteen patients underwent stapled haemorrhoidopexy and eighteen underwent open haemorrhoidectomy. All patients were reviewed immediately after surgery, at discharge and at 1, 3 and 10 weeks post-operatively. The two groups were compared for post-operative outcomes and complications.Results: The majority of patients in the study were males and had grade 4 haemorrhoids. Stapled haemorrhoidopexy group had shorter duration of surgery, less postoperative pain, shorter duration of hospital stays as compared with open haemorrhoidectomy group. There were no major post-operative complications in the follow up period of 10 weeks in the stapled group.Conclusions: Stapled haemorrhoidopexy is a safer alternative to open haemorrhoidectomy with many short-term benefits.

Stapled Haemorrhoidopexy in the Treatment of Haemorrhoidal Disease: A Prospective Study

Background: Haemorrhoids are usually managed by open haemorrhoidectomy which is associated with postoperative pain, prolong hospital stay, longer convalescence and late return to normal activities. Stapled haemorrhoidopexy is a newer alternative for the treatment of haemorrhoid. The present study was designed to evaluate this technique in terms of duration of surgery & hospital stay, complications, convalescence, time return to normal activities, cost effectiveness and patient’s satisfaction. Materials and methods: One hundred and sixty patients of either sex who fulfilled the criteria were included in this study. More than 90% of the patients were in grade 3 & 4. All data were prospectively collected and examined. The patients were evaluated in terms of demographic properties, complaints on admission and postoperative complication. Results: 69.4% were male and 30.6% were female. Mean age was 40.93 years. Grade 3 haemorrhoid was present in 73.75% cases, Grade 4 was 18.12% cases, Grade 1 and Grade 2 were in 8.13% cases. The mean duration of surgery was 30 minutes. The mean duration of hospitalization was 36 hours. Intraoperative bleeding was observed in 9.38% patients. Reactionary haemorrhage was seen in 3.75% patients. Postoperative mild pain in 3.12% patients and residual prolapse in 1.25% cases. Conclusion: Stapled haemorrhoidopexy is safer alternative to open haemorrhoidotectomy with many short and long term benefits. J Bangladesh Coll Phys Surg 2020; 38(3): 126-134

Our initial experience of three versus two rows circular stapler devices for stapled hemorrhoidopexy: a single institution review of 224 cases

Background: Stapled haemorrhoidopexy is a non-excisional approach for haemorrhoids as opposed to conventional open Milligan-Morgan and Ferguson closed haemorrhoidectomy techniques. It repositions the prolapsed haemorrhoid tissue and also causes vascular interruption to the haemorrhoids. This causes faster recovery and lesser post-operative pain.Methods: In authors institute, stapled haemorrhoidopexy was being carried out using two rows proximate PPH circular haemorrhoidal stapler. In February 2018, MIRUS three rows circular stapler was introduced. This is a retrospective observational study carried out at Artemis Hospital, Gurgaon, India. Authors studied records and operative notes of all patients who underwent stapled haemorrhoidopexy between February 2018 and September 2019 and compared key parameters.Results: A total of 224 patients underwent stapled haemorrhoidopexy between February 2018 and September 2019. 116 using MIRUS three rows circular stapler and 108 using two rows proximate PPH circular haemorrhoidal stapler. Most of the studied parameters were comparable with only significant statistical difference seen in higher use of haemostatic sutures in two rows stapler group compared to three rows stapler group. Haemostatic sutures were needed in three row stapler group for 27 patients and in two rows stapler group for 39 patients.Conclusions: Author’s initial experience shows slightly better haemostasis with three rows stapled haemorrhoidopexy with no significant difference in other parameters.