Stapled haemorrhoidopexy: is it time to move on?

Stapled haemorrhoidectomy was proposed as an ‘ideal’ solution for symptomatic haemorrhoids, with minimal postoperative pain, no perianal wound requiring postoperative wound care and a relatively short operative time. Some randomised controlled trials and reviews confirmed these findings, claiming that stapled haemorrhoidopexy is the most effective and safe procedure for haemorrhoids. However, there are increasing number of publications highlighting that the technique is associated with serious and life threatening complications. Maybe it is now the time to accept that stapled haemorrhoidopexy has done its role in directing our attention to the fact that modern surgical treatment of haemorrhoids should avoid excision of anorectal skin but should instead aim at treatment intervention above the dentate line.     

Randomized clinical trial of stapled haemorrhoidopexy versus conventional diathermy haemorrhoidectomy

BACKGROUND: The aim of this study was to compare the results of stapled haemorrhoidopexy (commonly called stapled haemorrhoidectomy) with those of conventional diathermy haemorrhoidectomy. METHODS: Fifty-five patients with symptomatic third- and fourth-degree haemorrhoids were randomized to either stapled haemorrhoidopexy (n = 27) or conventional diathermy haemorrhoid ectomy (n = 28). Operating time, postoperative pain, time to return to work, postoperative complications and effectiveness of haemorrhoidal symptom control were recorded. The mean follow-up was 15.9 months in the stapled haemorrhoidopexy group and 15.2 months in the conventional haemorrhoidectomy group. RESULTS: Mean pain intensity was significantly less in the stapled group (P = 0.001). There were no significant differences in the total number of complications, the length of absence from work or control of symptoms. Seven patients in the stapled group re-presented with prolapse compared with none in the conventional haemorrhoidectomy group (P = 0.004). This difference was also observed in the subset of patients with fourth-degree haemorrhoids (P = 0.003). CONCLUSION: The stapled operation was significantly less painful than conventional haemorrhoidectomy. However, the rate of recurrent prolapse was higher after stapled haemorrhoidopexy than after conventional diathermy haemorrhoidectomy.     

Sept ans d’hémorroïdopexies : des premiers essais contrôlés aux méta-analyses

Background

Surgical haemorrhoidectomy is reputed to be a painful procedure for a benign disorder. The circular transanal stapled technique for the treatment of haemorrhoids has the potential to offer a less painful rectal procedure in place of ablative perianal surgery. We compared the short-term outcome of the circular stapled procedure for haemorrhoids with current standard surgery in a randomised controlled trial.

Method

Fourty patients admitted for surgical treatment of prolapsing haemorrhoids were randomly assigned to either Milligan-Morgan haemorrhoidectomy (n = 20) or the circular stapled procedure. Under general anaesthesia patients underwent standardised diathermy excision haemorrhoidectomy or had a circumferential doughnut of rectal mucosa and submucosa above the dentate line excised and closed with a standard circular end-to-end stapling device. All patients received standardised preoperative and postoperative analgesic and laxative regimens. Patients completed linear analogue pain charts each day and were interviewed at 1, 3, and 6–10 weeks postoperatively. Summary measures of average pain experience were calculated from 10 cm linear analogue pain scores and were used as the primary outcome measure.

Findings

The stapled group had shorter anaesthesia time (median 18 [range 9–25] vs 22 [15–35] minutes). Average pain in the stapled group was significantly lower than it was in the Milligan-Morgan group (2.1 [0.2–7.6] vs 6.5 [3.1–8.5], 95.1 % CI difference medians 1.9–4.7, p < 0.0001. Mann-Whitney U test). Average pain relative to what the patient expected was also significantly less in the stapled group (?2.8 [?4.4 to 1.3] vs 0.7 [?1.8 to 3.4]). Hospital stay and time to first bowel motion were not significantly different between groups. Return to normal activity was significantly shorter in the stapled group (17 [3–60] vs 34 [14–90]). Early and late complications, patient-assessed symptom control, and functional outcome appear similar after short-term follow-up.

Interpretation

The circular stapled technique offers a significantly less painful alternative to Milligan-Morgan haemorrhoidectomy and is associated with an earlier return to normal activity. Early symptom control and functional outcome appear similar. However, long-term symptomatic and functional outcome need further study.     

Delayed presentation of life-threatening perineal sepsis following stapled haemorrhoidectomy: a case report

Fournier's gangrene has been described after injection sclerotherapy and banding of haemorrhoids as well as after conventional haemorrhoidectomy. In addition, there have been several cases following stapled haemorrhoidopexy. A patient with this complication nearly always presents within the first week following surgery. We present an illustrative case of a patient who underwent stapled haemorrhoidopexy for prolapsed haemorrhoids and presented with fever, urinary retention and peri-anal pain 39 days later. At re-operation, there was extensive peri-anal necrosis. After wide excision and fashioning of a colostomy, the patient recovered. Our case shows that late presentation can occur.     

A prospective evaluation of stapled haemorrhoidopexy/rectal mucosectomy in the management of 3rd and 4th degree haemorrhoids

Objective We have audited our 5 years experience of circumferential‐stapled haemorrhoidopexy (PPH). Method A prospectively collected electronic data base of our 5‐year experience to September 2005 has been examined. Results A total of 357 consecutive patients (220 – 62% women, median age 46 years; range 28–92) with symptomatic third‐ and fourth‐degree haemorrhoids (ratio 222:135) have undergone a stapled haemorrhoidopexy/rectal mucosectomy. One hundred and thirty‐two (37%) had failed previous banding; 42 (12%) had undergone a Milligan–Morgan haemorrhoidectomy in the past. All but one was performed under general anaesthetic. Mean duration of surgery was 15 min (range 11–40); 299 (84%) were planned day cases (three patients were admitted overnight for pain relief (2) and retention of urine) and 57 were planned successful overnight stays. Reactive postoperative bleeding requiring a blood transfusion occurred in three patients (0.8%): one returned to theatre (0.2%). Three patients (0.8%) had a secondary haemorrhage requiring a hospital visit, one was admitted overnight. Four patients complaining of severe pain were managed in the community. Transient urgency was reported in 92 patients (26%); 58 (63%) were men, faecal impaction 4 (1.1%), minor staple line stenosis requiring dilatation 5 (1.4%), peri‐anal sepsis from an associated untreated chronic anal fissure 1 (0.2%). Normal work was resumed between 3 and 31 days (median 7). Five patients re‐presented with recurrent symptoms between 14 & 18 months: further treatment comprised a repeat PPH in three (one was very painful), banding 1 and reassurance alone. A further patient re‐presented with minor soiling which responded to physiotherapy. Conclusion Stapled haemorrhoidopexy/rectal mucosectomy is a safe, effective and predictable treatment of third‐ and fourth‐ degree haemorrhoids and in the majority of patients can be carried out on a day case basis.     

Randomized clinical trial of sutured versus stapled closed haemorrhoidectomy

BACKGROUND: Stapled haemorrhoidectomy does not involve dissection, with its attendant potential morbidity, required to perform closed haemorrhoidectomy. This study compared haemorrhoidectomy with (sutured) and without (stapled) preliminary dissection. METHODS: Forty patients with prolapsed symptomatic haemorrhoids were randomly assigned to sutured (n = 20) or stapled (n = 20) haemorrhoidectomy. Preoperative assessment was by proctoscopy, sigmoidoscopy and anal manometry. Stapled and diathermy haemorrhoidectomies with wound suture were performed, and excised tissue was examined histologically. Pain scores, complications, wound healing and patient satisfaction were recorded. Follow-up was weekly for 4 weeks, and at 3 and 6 months; anal manometry was repeated at the last two visits. RESULTS: Postoperative resting and squeeze pressures were reduced by the stapled method at 3 months (P = 0.02 and P = 0.03 respectively), returning to baseline by 6 months. Stapled haemorrhoidectomy was quicker but initial access into the anus was hampered by the bulky stapler. Isolated muscle fibres were identified equally in both groups, but incontinence did not occur. The stapled technique resulted in less postoperative pain (P = 0.04), a greater degree of satisfaction (P = 0.01) and faster wound healing (P < 0.001), but was more expensive. There was no significant difference in complications. CONCLUSION: Despite the higher cost and difficult access, stapled haemorhoidectomy results in less postoperative pain, faster wound healing and greater patient satisfaction than the sutured technique.     

Day case stapled anopexy for the treatment of haemorrhoids and rectal mucosal prolapse

Aim Stapled anopexy (SA) gives better early postoperative results than classical haemorrhoidectomy. The aim of this study is to demonstrate that SA is a safe and effective procedure for the treatment of haemorrhoids and rectal mucose prolapse in a day‐case surgery programme. Method From January 2000 to December 2008, 297 SA procedures were performed; 230 (77.4%) were performed in the Day Surgery Unit (DSU). Third‐ and fourth‐degree haemorrhoids, second‐degree haemorrhoids with no response to conservative treatment and several cases of rectal prolapse were included. The mean age of the patients in the series was 48.1 years (range 21–85). Preoperative preparation included phosphate enemas and antibiotic prophylaxis. Patients were operated on mainly under spinal anaesthesia. Day‐case rate, postoperative pain (measured by a visual analogic scale, 1–10), admissions, re‐admissions, early postoperative situation and recurrence were evaluated in the study. Results The overall DSU rate was 78%, with a progressive increase from 46% to 99% in 2008. One hundred and eighty‐five patients (80%) had pain scores under 2; no patient had a pain score over 7. Eighteen (8%) patients required admission on the day of surgery. Late admission was needed for 3 (3%) patients. Thirty‐three patients reported their situation as excellent, 174 as good, 20 as acceptable and three as bad when they answered a phone questionnaire 24 h after surgery. Overall, 20 (9%) patients had recurrence of symptoms. Conclusion SA is a safe and effective procedure for prolapsing haemorrhoids in the day case setting. The recurrence rate is higher than that observed in classical haemorrhoidectomy. Most patients can be managed as day‐cases.     

Stapled haemorrhoidectomy compared with Milligan-Morgan excision for the treatment of prolapsing haemorrhoids: a prospective study.

OBJECTIVE: To compare stapled haemorrhoidectomy with Milligan-Morgan haemorrhoidectomy. DESIGN: Prospective open study. SETTING: Teaching hospital, Greece. PATIENTS: 85 patients with prolapsing haemorrhoids were invited to choose between stapled and Milligan-Morgan haemorrhoidectomy. 48 chose the former and 37 the latter. INTERVENTIONS: Operation. Postoperatively, the patients were given analgesics on demand, and were discharged as soon as their condition and particularly their pain had improved. MAIN OUTCOME MEASURES: Patients' symptoms and their opinion about the procedures, which were recorded during their follow-up which lasted for 6 months. RESULTS: Stapling resulted in a significantly shorter operating time, and less postoperative pain and other symptoms, than Milligan-Morgan excision (p < 0.001). Postoperative complications, and mean time in hospital did not differ significantly between the two groups. During the follow-up period there was no significant difference in the incidence of recurrences between the two groups. Six months after the operation, significantly more patients in the stapled group had residual skin tags-external haemorrhoids than in the Milligan-Morgan group, and all these patients had fourth degree haemorrhoids. CONCLUSIONS: Stapled haemorrhoidectomy is a promising method of treatment for prolapsing third degree haemorrhoids. Its effectiveness is questionable for fourth degree ones. Initially, the results are as good as after Milligan-Morgan haemorrhoidectomy, especially for third degree haemorrhoids. However, more patients and longer follow-up periods are required for its long-term efficacy to be confirmed.     

Randomized clinical trial of stapled versus Milligan-Morgan haemorrhoidectomy

BACKGROUND: The introduction of a stapling technique for the treatment of haemorrhoids has the potential for less postoperative pain, a short operating time and an early return to full activity. The outcome of stapled haemorrhoidectomy was compared with that of current standard surgery in a randomized controlled study. METHODS: Two hundred patients were randomized to either stapled haemorrhoidectomy (n = 100) or Milligan-Morgan haemorrhoidectomy (n = 100) between March 1997 and December 1998. Each patient received standardized postoperative analgesic and laxative regimens, and completed a linear analogue pain score every 6 h during the first day after operation, after the first motion and daily until the end of the first week. Operating time, frequency of postoperative analgesic intake, hospital stay, time to return to normal activity and postoperative complications were also recorded. RESULTS: The mean(s.d.) age of patients in the stapled and surgical groups was 44.1(3.2) and 49.1(12.2) years respectively. The stapled group had a shorter operating time, less frequent postoperative analgesia intake, shorter hospital stay and earlier return to normal activity. Early and late complications, and functional outcome were better in the stapled group. CONCLUSION: Use of a circular stapler in the treatment of haemorrhoidal disease was safe, and was associated with fewer complications than conventional haemorrhoidectomy.     

吻合器痔环切术治疗环状脱垂性内痔吻合口部位选择的临床价值

目的 通过对痔吻合器环切术吻合口与齿线间距离变化所对应的各个临床指标变化的比较分析,研究吻合口与齿线间距离选择在Ⅲ～Ⅳ度环状脱垂性内痔临床治疗上的意义. 方法对106例Ⅲ～Ⅳ度环状脱垂性内痔患者行吻合器痔环切术,术中测定吻合口与齿线间距离,术后对各患者各项临床指标(包括排便失禁评分、术后疼痛评分、出血、肛缘水肿、残留皮赘等局部并发症以及满意度)进行统计,研究分析吻合口齿线间距离对临床指标的影响,探讨吻合口齿线间距离的选择在吻合器痔环切术治疗中的意义. 结果根据测得的吻合口与齿线间距离将106例患者分成4组,其中吻合口与齿线间距离小于1.0 cm为A组,有20例,在1.0～1.5 cm间为B组,有40例,在1.5～2.0 cm间为c组,有37例,距离大于2.0 cm为D组,有9例.4组在术后Wexner肛门失禁评分、肛门出血评分、肛门局部并发症评分、满意度评分上无差别,在术后疼痛评分4组之间有显著差异,A组术后早期的疼痛较其余3组明显. 结论应用吻合器痔环切术治疗Ⅲ～Ⅳ度环状脱垂性内痔时,针对痔不同的脱垂程度选择适宜的吻合口部位,临床治疗效果良好.     

Stapled haemorrhoidopexy for prolapsed haemorrhoids: short- and long-term experience

OBJECTIVE: In prolapsed haemorrhoids, there is a permanent outward displacement of the mucosa of the anal canal, often involving the rectal mucosa. On this background, Longo set up a technique in 1998 to reduce haemorrhoidal prolapse, using a circular stapler. The aim of this study is to report our 7 years of experience on patients treated using this new surgical technique for haemorrhoids. METHODS: Between October 1998 and June 2005, 496 patients were treated by stapled haemorrhoidopexy. We analysed data from 300 of these patients in whom follow-up was longer than 12 months. RESULTS: The duration of the procedure ranged from 12 to 45 minutes. In 184 patients (37%), haemostatic stitches of the suture line were necessary after firing the stapler. Pain score (visual analogue scale, 1-10) after 24 hours ranged from 2 to 4 and after 5 days from 1 to 3. The average length of hospital stay was 2.3 days. Long-term results showed that only 9% of patients required further treatment after long follow-up, while 10.1% complained of some discomfort or residual symptoms in the perianal region. CONCLUSION: Our short- and long-term results show that stapled haemorrhoidopexy for haemorrhoids is a safe procedure with less pain and lower complication rate compared to conventional haemorrhoidectomy.     

Long stapled haemorrhoidectomy versus Milligan-Morgan procedure: short- and long-term results of a randomised, controlled, prospective trial

The aim of this study was to assess the short- and long-term results of treatment for haemorrhoids by prospectively comparing two techniques, namely, stapled rectal prolapse mucosectomy according to Longo and open hemorrhoidectomy. One hundred consecutive patients were randomised to stapled (50 patients) or manual hemorrhoidectomy (50 patients). We analysed postoperative pain, preoperative and postoperative anorectal function, intraoperative and postoperative complications, time needed to return to work and to normal social activities, and costs. Long-term follow data were obtained by means of an outpatient visit. The operative time of the stapled technique was less than that of open haemorrhoidectomy (22 vs 35 minutes). Two cases of early postoperative bleeding occurred after the stapled technique. The mean pain score on a visual scale was significantly less in patients undergoing the stapled technique. In addition, the time needed to return to work and to normal social activities was significantly less after the stapled technique, which, however, proved to be a more expensive procedure. Stapled mucosectomy of the prolapsed rectal mucosa is a safe, rapid, and relatively painless technique, which has a low incidence of complications. It can be performed in a day surgery unit. Patient satisfaction, early return to normal activities and good long-term results counterbalance the high cost of the procedure.     

Stapled haemorrhoidopexy transiently decreases rectal compliance and sensitivity

Aim Stapled haemorrhoidopexy may damage the anorectal musculature and its sensorimotor function. Most studies have not used a barostat for the measurement of compliance. This study aimed to investigate the effect of stapled haemorrhoidopexy on rectal compliance and sensitivity. Method After Ethical Committee approval, we studied 10 male patients (mean age 33.8 years) with third‐ or fourth‐degree haemorrhoids. Rectal compliance and sensitivity were measured with a 600‐ml bag and an electronic barostat. Volunteers were submitted to two consecutive rectal distension protocols, including continuous distension at 2, 4 and 6 months after stapled haemorrhoidopexy. Intraluminal volume and pressure were recorded, including the first rectal sensation, desire to defecate and onset of rectal pain. Another group of 10 male control patients (mean age 24.9 years) with pilonidal sinus and no haemorrhoids was also included in the study. Results Two months after stapled haemorrhoidopexy, rectal compliance decreased (7.1 ± 0.2 vs 5.3 ± 0.1, 6.4 ± 0.1 vs 5.1 ± 0.1 and 5.6 ± 0.2 vs 4.7 ± 0.1 ml/mmHg for first rectal sensation, desire to defecate and rectal pain, respectively; P < 0.05). The sensitivity threshold volume did not change for the first sensation but decreased significantly for the desier to defecate and pain (p <0.05) (116.8 ± 13.8 vs 148.4 ± 14.61, 251.1 ± 8.9 vs 185.8 ± 8.6 and 293.3 ± 16.6 vs 221.2 ± 6.0 ml for first rectal sensation, desire to defecate and rectal pain, respectively). Four and 6 months after surgery, rectal compliance and sensitivity returned to levels similar to those in the basal period. Muscle tissue was found in only three of the 10 resected doughnuts. Controls remained without any change in rectal compliance and sensitivity. Conclusion Stapled haemorrhoidopexy transiently decreases rectal compliance and sensitivity threshold in young male patients.     

Bleeding after stapled haemorrhoidopexy using the PPH 03 stapler device. Experience and results in 100 consecutive patients

Bleeding after stapled haemorrhoidopexy using the PPH 01 device is a relatively frequent major complication. Using the new PPH 03 instrument may enable to achieve better control. From June 2004 to July 2005, 100 patients with 2nd and 3rd degree haemorrhoids and mucosal rectal prolapse were treated at our institution. In all of the cases the PPH 03 instrument was used and the operations were performed by two surgeons with expertise in stapled haemorrhoidopexy. During structural interviews, the patients assessed their symptoms before and after surgery, and surgical outcome was assessed at 1 and 2 weeks. Major bleeding (loss of Hb > 5 points) occurred in 2 patients in the first 10 cases and re-operation was necessary. Minor bleeding (loss of Hb < 3 points) occurred in 2 patients. We had 2 bleeds in the early postoperative period (2%) and 2 cases of late bleeding (2%). Stapled haemorrhoidopexy is an effective treatment for haemorrhoids and is a significantly less painful operation. Any postoperative bleeding that may occur is easy to resolve and its incidence depends on the careful haemostatic control at the staple line. The new PPH 03 stapler device seems to be more effective than the PPH 01 device for control of the staple line suture. We would suggest that colorectal surgeons who are familiar with the technique and aware of possible complications should perform stapled haemorrhoidopexy using the PPH 03 stapler.     

Prospective randomized multicentre trial comparing stapled with open haemorrhoidectomy

BACKGROUND: The aim of this study was to compare the results of conventional open haemorrhoidectomy as currently practised in Italy (group 1) with stapled haemorrhoidectomy using a 33-mm circular stapling device (group 2). METHODS: One hundred patients with symptomatic third- and fourth-degree haemorrhoids were enrolled by five hospitals. Patients were allocated to the two groups according to a centralized randomization scheme featuring five permutated blocks of 20. Preoperative clinical examination and anorectal manometry demonstrated no features of anal incontinence. Patients had a clinical and manometric re-evaluation after operation and were asked to complete a clinical diary. After a median of 16 (range 8-19) months patients were administered a standardized questionnaire by telephone. RESULTS: Postoperative bleeding requiring haemostatic procedures occurred in three patients in each group. Patients in group 1 complained of moderate pain for a median of 5.3 (range 0-19) days compared with 3.1 (range 0-10) days in group 2 (P = 0.01), while severe pain was present for 2.3 (range 0-24) days in group 1 but only for 1 (range 0-14) day in group 2 (P = 0.03). The median hospital stay was 2 days in group 1 compared with 1 day in group 2 (P = 0.01). In the early days after operation, patients in group 2 had greater difficulty in maintaining normal continence to liquid stools (P = 0.01), but after 30 days the continence score was better in group 2 (P = 0.04). CONCLUSION: Stapled haemorrhoidectomy is as effective as conventional haemorrhoidectomy. Reduced postoperative pain, shorter hospital stay and a trend toward earlier return to work suggest short-term advantages for the stapled technique.     

Recurrent Symptoms after Stapled Haemorrhoidopexy and the Impact on Patient Satisfaction after a Minimum of 2 Years Follow-up

Background : Stapled haemorrhoidopexy came as an attractive alternative to treat grade 3 haemorrhoids. This study aims to assess the nature of recurrent symptoms and the impact on patient satisfaction after a minimum follow-up of two years in a group of patients who underwent stapled haemorrhoidopexy.

Methods : A standardized questionnaire was used to evaluate a consecutive group of patients by telephone treated by a stapled haemorrhoidopexy between January 2004 and December 2007. Outcome assessment comprised residual symptoms, subsequent treatment, and patient satisfaction.

Results : Hundred sixty-five patients underwent a stapled haemorrhoidopexy in the study period. Twenty-five patients (15%) were lost to follow-up. The included 140 patients presented with grade 2 (16) or grade 3 (124) prolapsing internal haemorrhoids. Median age was 50 years (range 27–79) and 56% were males. Median follow-up was 43 months (range 25–87). At final follow-up, 79 patients (56%) remained symptom-free. Nevertheless, 89% were more than satisfied. Only 11% were disappointed with the ultimate outcome. Recurrent symptoms were prolapse (52 patients), anal bleeding (46 patients), anal pressure or pain (24 patients) and pruritus (21 patients). Thirty-five patients had subsequent therapy: 20 underwent surgical resection and 15 had sclerotherapy or rubber band ligation. Patient satisfaction correlates with the number of recurrent (residual) symptoms and the need for further treatment.

Conclusion : Despite the high symptomatic recurrence rate after stapled haemorrhoidopexy, 89% of patients were satisfied. This suggests that recurrent or residual symptoms after stapled haemorrhoidopexy are often less severe compared to the initial presenting symptoms.     

Conversion in transanal stapling techniques for haemorrhoids and anorectal prolapse

Aim It was the aim of this single‐surgeon series to assess the role of conversion in transanal stapling to techniques and to identify potential factors predictive of conversion. Method The details of all consecutive patients who were planned for a stapled approach were prospectively recorded in a PC database. Stapling techniques (PPH03, PPH01 and ContourTranstar) were indicated for haemorrhoidal disease and internal rectal prolapse. ‘Conversion’ from a stapled approach was defined as an unplanned change of the surgical method to a nonstapled, traditional technique, related to indication, anatomy and technical factors. The primary outcomes were whether the procedure was performed using a stapling device only, or whether the procedure was converted. Logistic regression analysis was performed to evaluate multiple variables as potential risk factors for conversion. Results In a 2‐year period (May 2006–May 2008), 258 patients met the inclusion criteria and underwent transanal surgery scheduled as a stapled approach. In these 258 patients, 246 procedures were completed as a stapled procedure [that stapled haemorrhoidopexy, n = 148; stapled mucosectomy, n = 52; stapled transanal rectal resection (STARR) with PPH01, n = 38; and STARR with ContourTranstar, n = 8], giving a completion rate of 95.4%. However, 12 procedures were converted to conventional surgery (including traditional haemorrhoidectomy and the Delorme procedure), giving a conversion rate of 4.6%. The reasons for conversion were related to anatomy and to clinical findings (nonreducible haemorrhoidal prolapse), to new clinical findings not detected preoperatively (proctitis, anal fistula) and to a technical inability to insert the circular anal dilatator because of a deep anal canal. Neither univariate nor multivariate analysis identified any factor to be specifically associated with the risk of conversion. Conclusion In the era of transanal stapling procedures for haemorrhoids and anorectal prolapse, the majority of procedures can be performed using stapled techniques if strict criteria of indication and patient selection are respected. However, the current study identified a 4.6% conversion rate to traditional treatment, which has an impact on informed consent and requires the surgeon to be familiar with conventional anorectal procedures.     

Sacral nerve modulation in the treatment of chronic pain after pelvic surgery

Aim The aim of the study was to evaluate the efficacy of sacral nerve modulation for chronic pelvic pain after pelvic or anal surgery for benign disease. Method From January 2004 to December 2009, 17 (14 female; age 56 years) consecutive patients suffering from chronic pelvic pain underwent evaluation for sacral nerve modulation in three pelvic floor units. Results The previous surgery included stapled transanal rectal resection (five), hysterectomy (four), haemorrhoidectomy (two), stapled haemorrhoidopexy (one), fistulectomy (one), urethral sphincterotomy (one), appendicectomy (one), discectomy (one) and laparoscopy for endometriosis (one). Eight (47%) patients fulfilled the criteria for definitive implantation and were followed for a mean of 39 months. Using a visual analog pain score, pain levels fell from 8.2 preoperatively to 1.9, 2.1, 2.0 and 1.8 at 6, 12, 24 and 36 months, respectively. Age < 60 years and duration of symptoms of < 24 months were good predictors and stapling was a poor predictor of success. Conclusion Sacral nerve modulation seems to be effective over time in some patients with chronic pain related to previous surgery.     

Day case haemorrhoidectomy

OBJECTIVE: Day case haemorrhoidectomy in a District General Hospital. We have investigated the uptake and outcome of day case haemorrhoidectomy in a small district general hospital. METHOD: Case note review with completion of standard proforma for all patients undergoing haemorrhoidectomy as day case (same day admission and discharge) or inpatient over a 4-year period. RESULTS: Sixty patients underwent day case closed haemorrhoidectomy, 2 day case stapled haemorrhoidectomy and 1 day case open haemorrhoidectomy, whilst 18 patients were treated as in-patients. One patient required re-admission within 31 days for reactionary haemorrhage after day case surgery. None suffered acute urinary retention. Concomitant medical disease or emergency admission were the only reasons for exclusion from day case haemorrhoidectomy. Of the 18 patients treated as in-patients haemorrhoidectomy two had unplanned readmission. CONCLUSION: Closed haemorrhoidectomy with same day discharge should be offered to all patients that require surgical treatment of haemorrhoids and do not have other contra-indications to day case surgery.     

Modified stapled haemorrhoidectomy: a suggested improved technique

Background: Longo’s technique of stapled haemorrhoidopexy has revolutionized management of symptomatic haemorrhoids. However, several problems have been identified in the original Longo’s technique. In particular, recurrence of haemorrhoidal tissue has been found to be significantly higher. Methods: An improved technique with key differences to address these shortcomings is described. The modified stapled haemorrhoidectomy procedure described is carried out without the circular anal dilator and includes the placement of a low purse string of 2–3 cm. Conclusion: This technique is proposed as an improvement to the current stapled haemorrhoidopexy.