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Eur Surg (2008) 40/1: 30–33DOI 10.1007/s10353-007-0377-6# Springer-Verlag 2008 Long term results after stapled anopexy for symptomatichaemorrhoidal prolapse S. Riss1, P. Riss1, M. Schuster2, and T. Riss2 1 Division of General Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria2 Department of Surgery, Hartmannspital, Vienna, Austria Received September 5, 2007; accepted November 28, 2007# Springer-Verlag 2008 Langzeitergebnisse nach ,,Anopexie nach Longo‘‘ Summary. Background: Because of a lack of long-term bei symptomatischem Ha¨morrhoidalprolaps results, the present study was designed to assess the effec-tiveness of stapled anopexy after long-term follow-up.
Zusammenfassung. Grundlagen: Ziel dieser Studie Methods: 242 of 300 operated patients were available war eine Langzeitbeurteilung der Effektivita for follow-up (mean 48 months). For evaluation, a standard- nach Longo bei symptomatischem Ha¨morrhoidalprolaps.
ized questionnaire was used, including clinical symptoms Methodik: 242 Patienten (mittlere Follow-up-Dauer 48 and satisfaction. Anal anatomy was assessed by clinical Monate) wurden inkludiert. Zur Evaluierung klinischer Symptome (Schmerzen, Jucken, Blutung, Stuhldrang, Results: Patients judged their results as excellent in Stuhlinkontinenz) und Patientenzufriedenheit wurde ein 79.4%, good in 12%, fair in 5.7% and poor in 2.9% cases.
standardisierter Fragebogen entworfen. Zudem wurde zur Five patients (2.1%) showed recurrent prolapse and were anatomischen Beuteilung eine klinische Untersuchung operated by Milligan-Morgan procedure. Residual skin-tags were observed in 26.9% (n ¼ 65). Reoccurrence of haemor- rhoidal symptoms were bleeding (7.9%), itching (4.1%) and Patienten ihr Ergebnis mit ,,sehr gut‘‘, 12% ,,gut‘‘, 5,7% pain (3.3%). Adverse effects of surgery were stool urgency ,,ausreichend‘‘ und 2,9% ,,schlecht‘‘. 5 Patienten (2,1%) (4.5%), faecal incontinence (3.3%) and persistent pain Conclusions: Despite a high rate of residual skin- ten (Marisken) wurden in 26,9% (n ¼ 65) beobachtet. Erneut tags after stapled anopexy, our data revealed acceptable aufgetretene Symptome waren Blutungen in 7,9% (n ¼ 19), results in terms of patient’s satisfaction and definitive Juckreiz in 4,1% (n ¼ 10) und Schmerzen in 3,3% (n ¼ 8).
resolution of haemorrhoidal symptoms after a long term Chirurgische Nebenwirkungen waren Stuhldrang in 4,5% (n ¼ 11), Stuhlinkontinenz in 3,3% (n ¼ 8) und anhaltenderSchmerz in 3,3% (n ¼ 8).
Key words: Hemorrhoids, surgery, fecal incontinence, bliebenen a¨ußeren analen Hautfalten konnte die Studie einehohe Patientenzufriedenheit sowie eine akzeptable Beseiti-gung von Ha ¨ morrhoidalbeschwerden auch im Langzeit- Stapled anopexy, introduced by A. Longo in 1998, is ¨ rter: Ha¨morrhoiden, Chirurgie, Anopexie, based on a new concept of aetiology and treatment for haemorrhoidal piles [1]. A redundant rectal mucosa isconsidered to be the primary alteration for the pathogen-esis of the disease. This internal mucosal prolapse canocclude the rectal lumen, causing difficulties for thepassage of faeces. By a descensus and expulsion of the Correspondence: Stefan Riss, M.D., Division of General Sur-gery, Department of Surgery, Medical University of Vienna, haemorrhoidal tissue, the redundant mucosa is stretched Wa¨hringer Gu¨rtel 18–20, 1090 Vienna, Austria.
whereby the rectal lumen is freed and defecation en- abled. As a consequence of the pathogenetic concept, stapled anopexy removes the internal rectal prolapse S. Riss et al.: Long term results after stapled anopexy for symptomatic haemorrhoidal prolapse and does not resect the prolapsed haemorrhoidal tissue, which is rather lifted and fixed in a physiological po-sition. Additionally, the arterial inflow will be reduced The operation is performed in lithotomy position. The by interruption of the terminal branches of the superior anus is gently dilated by using the obturator. Perianal traction sutures are inserted at 3, 6, 9 and 12 O’clock to A number of randomized controlled studies compared fix the circular anal dilatator (Ethicon CAD 33). The trac- conventional techniques with stapled anopexy. Low post- tion sutures must not catch prolapsed tissue to enable the operative pain and the early return to work were regarded complete repositioning of the prolapsed piles. By means as great advantages over conventional methods. Conflicting of a special side open anoscope (Ethicon PSA 33), a purse results were obtained in terms of recurrent prolapse string suture is inserted into the mucous membrane of the and definitive cure of haemorrhoidal symptoms [2–8].
distal rectum, about 2–3 cm above the haemorrhoidal tis- However, most of the studies included a small number sue. Using a circular stapler device (Ethicon PPH 01), a of patients and had a short follow-up period.
mucosal doughnut is resected. The resulting stapler line is Because of a lack of long-term results, the present situated approximately 2 cm above the dentate line. Thus study was designed to assess the effectiveness of stapled the rectal venous plexus is not excised but lifted into the anopexy after a mean follow-up of 48 months.
proximal anal canal. Bleeding around the stapler line iscontrolled by absorbable sutures or by using diathermy.
The excised mucosal doughnut is measured and sent to From 1999 to 2005, 300 patients underwent stapled haemorrhoidopexy for symptomatic haemorrhoidal pro- lapse at one institution. 240 patients (100 female, 140male) were available for follow-up and retrospectively re- Early postoperative complications included urinary re- viewed. Mean age was 59 years (range 29–94 years) with tention (n ¼ 8, 3.3%), bleeding (n ¼ 3, 1.2%) and anal a mean follow-up time of 48 months (range 7–92 months).
stenosis (n ¼ 2, 0.8%). Patients with anal stenosis could In 4.1% (n ¼ 10) of the patients, a Milligan Morgan pro- be dilated successfully. Two patients (0.8%) suffered from cedure has been performed previously for symptomatic persistent anal pain in the follow-up period. In these cases the stapled line was excised under general anaesthesia During this time period stapled haemorrhoidopexy as and the mucosal defect adapted by absorbable sutures.
the only surgical technique that was offered to our patients Afterwards anal pain disappeared. Other side-effects of suffering from symptomatic haemorrhoidal prolapse.
surgery are shown in Table 2. Five patients (2.1%) showed Inclusion criteria were symptomatic haemorrhoidal recurrent haemorrhoidal prolapse and were operated with piles after conservative treatment failure. Patients were Milligan Morgan procedure. Residual skin tags were ob- excluded with acute haemorrhoidal episodes with throm- served in 26.9% (n ¼ 65) of the cases.
bosis, irreducible haemorrhoidal piles and intercurrent Postoperative patients judged their results as excellent anal pathologies (i.e. fissure, fistula, anal incontinence in 79.4% (n ¼ 192), good in 12% (n ¼ 29), fair in 5.7% not due to haemorrhoids’ disease). Patients with acute or (n ¼ 14) and poor in 2.9% (n ¼ 7). Concerning the ques- irreducible haemorrhoidal piles were treated by a Milligan tion, ‘‘Would you undergo surgery again, if necessary?’’ patients reported ‘‘yes’’ in 90.1% (n ¼ 218), ‘‘no’’ in 4.1% All operations were performed by one single surgeon.
(n ¼ 10), and ‘‘do not know’’ in 5.8% (n ¼ 14). Late post- Haemorrhoidal degree was staged as II in 20.2%, III operative haemorrhoidal symptoms were observed in in 76% and IV in 3.8% of the patients. We used the grad- 15.3% of the patients (n ¼ 37) and are listed in Table 3.
ing system published by Banov et al. in 1985 (Table 1) There was no correlation between preoperative haemor- [9]. Preoperative symptoms included bleeding (n ¼ 161, rhoidal stage and postoperative outcome.
66.5%), itching (n ¼ 81, 33.5%) and pain (n ¼ 129,53.3%). All patients were reviewed personally. To evalu- Table 2. Adverse effects of stapled anopexy ate patient’s outcome, a standardised questionnaire wasused, including clinical symptoms (pain, itching, bleeding, stool urgency, faecal incontinence) and patient’s satisfac- tion (excellent, good, fair, poor, ‘‘Would you undergo sur- gery again, if necessary?’’). Anal anatomy was assessed by clinical examination. Statistics have not been applieddue to the descriptive type of publication [10].
Table 3. Haemorrhoidal symptoms after a mean follow up of 48 Table 1. Grading system published by Banow et al. [9] Haemorrhoids that bleed but do not prolapse Haemorrhoids that prolapse but reducespontaneously Haemorrhoids that prolapse and require reduction Prolasped haemorrhoids that cannot be reduced S. Riss et al.: Long term results after stapled anopexy for symptomatic haemorrhoidal prolapse skin tags do not affect patient’s satisfaction and must notbe resected in the same procedure at stapled anopexy. If Severe surgical complications, such as Fournier’s gan- the patients wish to excise the skin tags at the same time, it grene, rectovaginal sepsis or rectal perforation were not would reduce the advantages of Longo’s technique of less seen in the current sample [11–14]. New onset anal pain, a postoperative pain and early return to work.
side-effect which persisted over the follow-up period were All in all, stapled anopexy seems to be effective for observed in 2 cases of the current study. A purse string the management of haemorrhoidal prolapse in terms of suture located close to the dental line, thus touching the patient’s satisfaction and definitive resolution of haemor- sensible anoderm, might be a reasonable explanation for rhoidal symptoms. Complication rate seems to be low anal pain. Notably, in our patients the stapled line was even after a long-term period. The risk of new symptoms, placed regularly about two centimetres above the dental like stool urgency and anal pain, exists, and has to be line. However, after conservative treatment failure, the explained to the patients preoperatively.
stapled line was excised and the mucosal defect adaptedby absorbable sutures. Afterwards anal pain disappeared.
Another successful therapeutic approach in case of new- onset postdefecation pain could be the use of the calciumchannel antagonist nifedipine [15]. The authors of that The authors thank Professor Friedrich Herbst for his study assumed the origin of pain was in the rectum, as anorectal measurement of anal sphincter pressures showedno reduction after the use of this oral medicament. Themucosubmucosal anastomosis is considered to alter neu- ronal innervations in the rectal musculature, resulting in 1. Longo A (1998) Treatment of haemorrhoids disease by re- rectal hyperactivity or spasm. The incidence of chronic duction of mucosa and hemorrhoidal prolaps with circu- anal pain after stapled anopexy remains uncertain, but lar suturing device: a new procedure. World Congress of can rise to 25% in certain series [16, 17].
Stool urgency and faecal incontinence which persisted 2. Hetzer FH, Demartines N, Handschin AE, Clavien PA up until the endpoint of the follow-up were additional (2002) Stapled vs excision hemorrhoidectomy: long-term adverse effects of stapled anopexy in the present study.
results of a prospective randomized trial. Arch Surg 137: In the literature it is discussed whether urgency is caused by sphincter-injury due to excessive anal stretching, or by 3. Kairaluoma M, Nuorva K, Kellokumpu I (2003) Day-case incorporation of rectal muscle layer into the resected stapled (circular) vs. diathermy hemorrhoidectomy: a ran- doughnut [18, 19]. A common explanation might also be domized, controlled trial evaluating surgical and functional the altered anatomy in the anal-rectum due to the lifted mucosal tissue, causing a decreased threshold for the stim- 4. Mehigan BJ, Monson JR, Hartley JE (2000) Stapling pro- ulus of defecation [16]. Studies of endoanal sonography as cedure for haemorrhoids versus Milligan-Morgan hae- manometric assessments did not detect any significant im- morrhoidectomy: randomised controlled trial. Lancet 355 pact of stapled anopexy [19]. All in all, it is unclear why 5. Rowsell M, Bello M, Hemingway DM (2000) Circumfer- some patients do have urgency matters, whereas others do ential mucosectomy (stapled haemorrhoidectomy) versus conventional haemorrhoidectomy: randomised controlled The aim of the current study was further to assess the effectiveness of stapled anopexy as a definitive cure for 6. Senagore AJ, Singer M, Abcarian H, Fleshman J, Corman haemorrhoid-related symptoms. A Cochrane Database re- M, Wexner S, et al. (2004) A prospective, randomized, view of randomized controlled studyies, comparing stapled controlled multicenter trial comparing stapled hemorrhoi- anopexy with Milligan Morgan procedure, observed recur- dopexy and Ferguson hemorrhoidectomy: perioperative and rent haemorrhoids in 23 out of 269 patients in the stapled one-year results. Dis Colon Rectum 47: 1824–1836 group in contrast to 4 out of 268 patients in the conven- 7. Ganio E, Altomare DF, Milito G, Gabrielli F, Canuti S tional group [20]. Moreover, patients with stapled anopexy (2007) Long-term outcome of a multicentre randomized seemed more likely to complain of prolapse symptoms. In clinical trial of stapled haemorrhoidopexy versus Milligan- the present study, we had a longer follow-up time and a Morgan haemorrhoidectomy. Br J Surg 94: 1033–1037 higher rate of reoccurrence of haemorrhoidal symptoms.
8. Van de Stadt J, D’Hoore A, Duinslaeger M, Chasse E, Notably, a number of these patients reported sporadic Penninckx F (2005) Long-term results after excision hae- bleeding, which did not, however, affect their daily activity.
morrhoidectomy versus stapled haemorrhoidopexy for pro- A long-term follow-up study by Ganio et al. found no lapsing haemorrhoids; a Belgian prospective randomized differences between either surgical approach [7]. In con- trast, Van de Stadt et al. revealed a higher risk of reprolaps- 9. Banov L Jr, Knoepp LF Jr, Erdman LH, Alia RT (1985) ing piles requiring surgery after stapled anopexy [8].
Management of hemorrhoidal disease. J S C Med Assoc 81:398–401 A high number of our patients had residual skin tags, 10. Draxler W, Mittelbo¨ck M (2006) Basic principles in the plan- which were not automatically associated with clinical ning of clinical trials in surgical oncology. Eur Surg 38: 27–32 symptoms. Smyth et al. observed residual skin tags in 11. Bonner C, Prohm P, Storkel S (2001) Fournier gangrene 45% of their patients after stapled anopexy [21]. The ma- as a rare complication after stapler hemorrhoidec- jority of these patients was totally asymptomatic and re- tomy. Case report and review of the literature. Chirurg quired no additional treatment. In our experience, residual S. Riss et al.: Long term results after stapled anopexy for symptomatic haemorrhoidal prolapse 12. Molloy RG, Kingsmore D (2000) Life threatening pelvic sep- 17. Ng KH, Ho KS, Ooi BS, Tang CL, Eu KW (2006) Experi- sis after stapled haemorrhoidectomy. Lancet 355 (9206): 810 ence of 3711 stapled haemorrhoidectomy operations. Br J 13. Pescatori M, Aigner F (2007) Stapled transanal rectal mucosectomy ten years after. Tech Coloproctol 11: 1–6 18. Cheetham MJ, Mortensen NJ, Nystrom PO, Kamm MA, 14. Ripetti V, Caricato M, Arullani A (2002) Rectal perforation, Phillips RK (2000) Persistent pain and faecal urgency after retropneumoperitoneum, and pneumomediastinum after stapled haemorrhoidectomy. Lancet 356 (9231): 730–733 stapling procedure for prolapsed hemorrhoids: report of a 19. Ho YH, Seow-Choen F, Tsang C, Eu KW (2001) Random- case and subsequent considerations. Dis Colon Rectum 45: ized trial assessing anal sphincter injuries after stapled haemorrhoidectomy. Br J Surg 88: 1449–1455 15. Thaha MA, Irvine LA, Steele RJ, Campbell KL (2005) 20. Jayaraman S, Colquhoun PH, Malthaner RA (2006) Stapled Postdefaecation pain syndrome after circular stapled ano- versus conventional surgery for hemorrhoids. Cochrane pexy is abolished by oral nifedipine. Br J Surg 92: 208–210 16. Fueglistaler P, Guenin MO, Montali I, Kern B, Peterli R, von 21. Smyth EF, Baker RP, Wilken BJ, Hartley JE, White TJ, Flue M, et al. (2007) Long-term results after stapled hemor- Monson JR (2003) Stapled versus excision haemorrhoidect- rhoidopexy: high patient satisfaction despite frequent post- omy: long-term follow up of a randomised controlled trial.
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