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.

Postoperative recovery; Stapled Hemorrhoidopexy versus Conventional haemorrhoidectomy.

Conventional haemorrhoidectomy, a usual procedure for hemorrhoids in our set up have many short and long term complications. Some patients complained pain many weeks after surgery and are unable to do their routine work. Anal stenosis and recurrence are long term issues. There is need for some other procedure which can decrease postoperative pain and hospital stay. Objectives: To compare the postoperative recovery between stapled hemorrhoidopexy and conventional hemorrhoidectomy. Study Design: Randomized Clinical trial. Setting: Surgery Department of Nishtar Medical University Multan. Period: from 01-01-2018 to 31-12-2018. Material & Methods: Randomly 02 equal groups of the patients, A and B were made. Stapled hemorrhoidopexy (SH) and conventional haemorrhoidectomy was done in group A and B respectively. SPSS version 20 used for data analysis. Mean and standard deviation were used for quantitative variables including postoperative pain, age and hospital stay. Independent Student t test used for comparison of hospital stay and postoperative pain. Effect modifier including gender, age, duration and grade of hemorrhoids were controlled by stratification and Chi square test was applied. P value less than 0.05 was taken as significant. Results: Out of 60 patients, 32 were males and 28 females. In Group A (Stapled Hemorrhoidopexy), mean age was 37.37 + 6.36 years and 39.17 + 5.53 years in Group-B. Postoperative pain in Group A was 3.60 + 1.27 and 6.03 + 1.73 in Group B. Postoperative pain was significantly high in Group B (CH) and P value =0.000. Mean hospital stay was 0.90 + 0.48 days in Group A and 1.87 + 0.57 days in Group B with P value= 0.000. Conclusion: Stapled hemorrhoidopexy is associated with shorter hospital stay and decrease postoperative pain irrespective of age, sex and grade of the hemorrhoids.

Study Protocol for the Use of Conventional Open Haemorrhoidectomy versus Laser Haemorrhoidoplasty in the Treatment of Symptomatic Haemorrhoids: A Randomized Controlled Trial

Background: Haemorrhoids result in a variety of symptoms that cause significant patient anxiety. Treatment has long been associated with post-operative complications, which cause significant symptoms and may result in readmissions. The open conventional haemorrhoidectomy (COH) is still regarded as the gold standard treatment for non-circumferential grade II–IV haemorrhoids. Laser haemorrhoidoplasty (LAH) has recently been studied and the initial results appear promising. This study aims to compare these 2 techniques in the treatment of symptomatic haemorrhoids. We hypothesize that LAH has significantly less pain and bleeding and better quality of life (QoL) scores 1, 3 and 12 months post-operatively. Methods: A prospective, randomized, double-blind, single-centre clinical trial will be conducted. All patients aged between 21 and 90 years who present with symptomatic grade II–IV haemorrhoids will be recruited. Exclusion criteria include those who have had previous operations for haemorrhoids and those with an increased risk of bleeding. Data collected will include patient demographics, pre- and intra-operative characteristics of the haemorrhoids, operative details and post-operative pain Visual Analogue Scale (VAS) score, complications, readmissions, and haemorrhoid-specific QoL surveys. Primary outcome will be median post-operative pain VAS score on post-operative days (POD) 1–10. Secondary outcomes include operative duration, bleeding on the first 10 days post-operatively, readmissions, procedure-related complications (fistulation, incontinence, stenosis), QoL scores, and recurrence of symptoms up to 12 months. Discussion: Results from this trial may demonstrate the superiority of LAH over COH in terms of post-operative pain and recovery. This would likely increase the adoption of LAH for the treatment of symptomatic haemorrhoids. Trial Registration: This trial was registered on 1/4/2020 at ClinicalTrials.gov. URL: https://www.clinicaltrials.gov/ct2/show/NCT04329364?term=NCT04329364&draw=2&rank=1.

Plication: an innovative method of treating piles

Background: The cause of haemorrhoids remains unknown. Factors contributing to haemorrhoids are constipation, prolonged squatting, pregnancy, aging, heredity, portal hypertension, abdominal tumour etc.Methods: This prospective study was carried out in department of surgery, M.K.C.G MCH, Berhampur, Odisha, India from 01st August 1995 to 31st July 2017. Patients from both sex and different age groups having haemorrhoids were included. Patients with piles secondary to anorectal tumours, prolapsed and thrombosed piles, anorectal pathology like fissure were excluded from study. Preoperative, intraoperative interventions and postoperative care were carried out according to laid procedure described below.Results: Total 1014 patients of piles were selected for plication and conventional haemorrhoidectomy and most of them were between 31-50 years of age while 362 cases underwent plication, rest 346 cases were treated with haemorrhoidectomy. All patients in this study had bleeding per rectum as the main symptom. Out of 507 patients which has been examined for plication, 272 (53.65%) had 2nd degree, 235 (46.35%) had 3rd degree piles. Results of plication of piles are satisfactory and only 4% patients had pain for which long term analgesics were given.Conclusions: Treatment of haemorrhoids is well debated topic and various methods are being used by surgeons all over world. Plication of piles appears to have significant advantages over conventional methods in terms of patient comfort, duration of stay in hospital and incidence of complications. Literature on this subject is briefly reviewed.

Randomized comparison of stapled haemorrhoidopexy and open haemorrhoidectomy

Background: Surgical management of haemorrhoids is reserved for stage III and IV haemorrhoids. Both Milligan-Morgan technique (CH-Conventional Haemorrhoidectomy) and stapled haemorrhoidopexy technique are used as surgical therapy. Our prospective, comparative study of conventional haemorrhoidectomy versus stapled haemorrhoidectomy was designed in present institution.Methods: This prospective randomised comparative study was carried out in present Surgery Dept from July 2016 to December 2017 with total 60 sample size. All data were analysed according to applicable statistical methods. The results were compared to previous studies so as to arrive at a conclusion.Results: The mean duration of surgery with stapled method was 30.76±3.13 minutes and with conventional method was 49.36±4.08 minutes which was significantly high in conventional method. VAS scores for pain at 12 hours, 24 hours, 72 hours and 7 days for stapled group were 2.63±0.76, 1.66±0.88, 0.90±0.71 and 0.50±0.43 while that for the conventional group were 5.63±0.72, 4.56±1.22, 3.26±1.25 and 2.00±0.69. At all points of time the VAS was significantly lower in stapled group. The mean duration of hospital stay of the patients with stapled method was 3.10±0.75 days and with conventional method was 6.06±0.94 days, which was significantly high in conventional method. The mean time to return to normal activities of the patients with stapled method was 8.16±1.93 days and with conventional method was 12.60±1.67 days, which also significantly high in conventional method.Conclusions: Present study inferred that stapled haemorrhoidopexy is faster, minimally invasive for treatment of haemorrhoids as compared to Conventional haemorrhoidectomy. It is associated less pain and provides a more satisfactory alternative to Conventional surgery because of reduced hospitalisation and earlier return of patient to daily activities, with no significant differences in short term follow up.

Harmonic scalpel versus conventional haemorrhoidectomy for grade III and IV haemorrhoids: a randomized controlled trial

Background: Haemorrhoidal disease is one of the most frequently encountered anorectal condition in the clinical practice of a surgeon. Haemorrhoidectomy is the treatment of choice for grade III and IV haemorrhoids but is associated with significant postoperative pain and complications. Harmonic dissection causes less lateral tissue injury and thus less intra-operative bleeding and post-operative complications. The present study compares Harmonic Haemorrhoidectomy with conventional Haemorrhoidectomy.Methods: In a randomized controlled trial, patients with grade III and IV haemorrhoids satisfying inclusion and exclusion criteria were allocated to Harmonic scalpel haemorrhoidectomy or conventional Milligan Morgan open haemorrhoidectomy by block randomisation of 4. The outcome factors were intra operative blood loss, postoperative pain on VAS scale, urinary retention and anal stenosis after one month of follow up.Results: Total of 40 cases were enrolled. Of them, 22 were allocated to Harmonic haemorrhoidectomy, the rest 18 patients underwent conventional haemorrhoidectomy. The mean age of patients was 47.03 years with a Male to Female ratio of 1.35:1. Intraoperative blood loss measured by number of soaked gauze pieces and pain score measured on visual analogue scale at 12, 24 and 48hours was seen to be statistically significant (p<0.001) lesser in patients who underwent Harmonic scalpel haemorrhoidectomy. There was no statistically significant difference in operative time urinary retention or anal stenosis.Conclusions: Harmonic scalpel haemorrhoidectomy appears to be a better procedure for symptomatic grade III and grade IV haemorrhoids with ease of operating due to less bleeding, good postoperative recovery and patient acceptance.