Prolapso hemorroidal circunferencial mixto. Tratamiento combinado con sutura mecánica y fotocoagulación con láser / Mixed circumferential hemorrhoidal prolapse. Combined treatment with mechanical stapler and laser coagulation

RESUMEN El manejo del prolapso hemorroidal circunferencial representa un desafío para los cirujanos. Actualmente existen alternativas a los procedimientos convencionales; sin embargo, ninguna de éstas consideran el tratamiento de la enfermedad externa. Aun en los casos en que se utiliza un procedimiento como la hemorroidectomía con sutura mecánica o la ligadura de los paquetes guiados por Doppler, técnicas que se han asociado a un posoperatorio menos doloroso, estas no contemplan el tratamiento del componente externo. El objetivo de esta publicación fue presentar la técnica detallada para el tratamiento de pacientes con prolapso hemorroidal mixto, combinando los procedimientos de hemorroidopexia con grapas, seguida de una fotocoagulación con láser de las hemorroides externas. Los resultados han sido previamente documentados en un total de 25 pacientes. Se describieron complicaciones en un 4% de los casos, concluyendo que se trata de una alternativa para considerar ante pacientes con prolapso hemorroidal circunferencial con componente externo.

ABSTRACT Management of circumferential hemorrhoidal prolapse represents a challenge for surgeons. There are currently many alternatives to conventional procedures.; however, none of these techniques consider treatment of external disease. Even procedures associated with less postoperative pain as stapled hemorrhoidectomy or Doppler-guided hemorrhoidal artery ligation do not involve treatment of the external component. The aim of this publication is to present the technique detailed to treat patients with mixed hemorrhoidal prolapse, combining stapled hemorrhoidopexy with laser coagulation of external hemorrhoids. The results have been previously documented in a total of 25 patients, with 4% of complications. We conclude that the procedure is an option to consider in patients with circumferential hemorrhoidal prolapse with external component.

Treatment of grade four hemorrhoids in a patient with acute myeloid leukemia with severe thrombocytopenia by laser hemorrhoidopexy: A case report

Here, we present the case of a 66-year-old female patient with acute myeloid leukemia and severe thrombocytopenia who came with the complaints of painful per anal mass and bleeding per rectum for 1 year. The patient is a known case of hypertension, and diabetes mellitus and has received three cycles of chemotherapy with decitabine. On examination, she was found to have fourth-degree hemorrhoids at 3, 7, and 11 oclock positions with acute edematous changes. We successfully treated this patient with laser hemorrhoidopexy, whereby laser energy was delivered to each hemorrhoidal cushion. While lasers for the successful treatment of grade 2 and 3 hemorrhoids are well documented in the literature, we successfully treated this patient with prolapsing fourth-degree hemorrhoids with just laser energy delivery. With these results, we would also like to consider laser hemorrhoidopexy as an effective treatment option for four-degree hemorrhoids for which open Milligan–Morgan hemorrhoidectomy and stapler hemorrhoidectomy are currently considered treatment options

Assessment of Post-operative Complications, Recurrence Rate, and Patient Satisfaction After Undergoing Stapled Hemorrhoidopexy Intervention for Grades III and IV Hemorrhoids among Adult Patients of North India

Introduction: Hemorrhoids are one of the most frequent anorectal disorders encountered by clinicians in day-to-day practiceand constitute about 50% of colorectal investigations. Stapled hemorrhoidopexy (SH) represents the first dramatic change inthe treatment of hemorrhoids. Since its introduction, some researchers have raised concerns about the recurrence rate as wellas patient satisfaction. Hence, the present study was carried out to evaluate recurrence rate and patient overall satisfactionwith SH procedure at a tertiary care center in North India.Materials and Methods: Ethical clearance was obtained at the start of the study from the Institutional Review Board. A totalof 100 patients with Grade III/IV hemorrhoids were included. SH was performed as per the standard procedures. Data werecollected on complications developed post operatively at different follow-ups and an overall patient satisfaction. The data werecoded and entered into Microsoft Excel 2010.Results: Post-operative complications we observed at the 1st week were bleeding and discharge in 5%, pain in 9%, and urinaryretention in 11% of enrolled cohorts. At 1 month, hematoma formation was observed in 7.3% of total remaining patients (n = 96)and 5.2% still had post-operative pain. At 6 months, pruritus and stenosis were witnessed in 4.3% and 1.1%, respectively, oftotal remaining patients (n = 93). Recurrence rate was found 4.3% at the end of 6 months. The overall complication rates at 1week, 1 month, and 6 months follow-up were 25%, 12.5%, and 9.7%, respectively.Conclusion: The findings of our study confirm that SH is associated with a high patient satisfaction and with a lesser postoperative complications. We conclude that SH is safe with many short-term benefits.

A Prospective Comparative Study: Stapler Hemorrhoidopexy vs Laser Hemorrhoidoplasty in the Treatment of Hemorrhoids

Aims:Stapler hemorrhoidopexy (SH) has evolved over time as a procedure of choice over conventional surgery due to less postoperative pain. Laser hemorrhoidoplasty (LH) is a novel procedure aimed at shrinking the terminal branches of hemorrhoidal arteries with fewer complications. The present study is aimed to compare these procedures (SH and LH).Study Design:Prospective comparative study.Place and Duration of Study:Patients operated for hemorrhoids at the Department of General, MI & Bariatric Surgery, Artemis Hospitals, Gurgaon from April 2018 to March 2019. Methodology:50 patients with grade II-III hemorrhoids were allocated to two groups: Stapler hemorrhoidopexy(SH) and Laser hemorrhoidoplasty (LH) with 25 patients in each group. Results were compared and patients were followed up for minimum period of 3months Results:The mean operative time was 24.6 min (LH) and 28.6 min (SH) (P=.122). The average blood loss was 8.32 ml (LH) and 11.64 ml (SH) (P <.05). The mean hospital stay 21.44 hours (LH) and 32.64 hours (SH) (P <.05). Mean postoperative pain score (VAS) at 12 hours was 2.64 (LH) and 4.76 (SH) (P <.05), at 24 hours was 1.88 (LH) and 3.6 (SH) (P <.05), at 1 week was 0.36 (LH) and 0.88 (SH) (P =.054) and at 3 months 0.04 (LH) and 0.12 (SH) (P =.53). One patient in LH (4%) had postoperative bleeding on 4th postoperative day. In SH group, 2 (8%) had severe postoperative pain with VAS > 8, requiring longer hospital stay, 2 (8%) had bleeding on the same day, 1(4%) had bleeding on follow up and 1 (4%) had recurrence. Conclusion:In terms of early postoperative pain and complications, LH offers better results as compared to SH. It was associated with a shorter hospital stay and earlyreturn to work. No significant complications were noted in LH compared to SH. LH is an extremely viable alternative to the popular SH for grade II-III hemorrhoids.

Hemorroidopexia. Nuestra experiencia. Análisis descriptivo de las complicaciones de la técnica de hemorroideopexia con sutura mecánica y el grado de satisfacción / Hemorroidopexy Our experience. Descriptive analysis of the complications of the hemorrhoidepexy technique with mechanical suture and the degree of satisfaction

Introducción: La hemorroidopexia con sutura mecánica, es una técnica eficaz para los prolapsos hemorroidales grado III y IV. Objetivo: Describir nuestra experiencia con dicho método. Material y métodos: Se realizó un análisis descriptivo, retrospectivo sobre una base de datos cargada en forma prospectiva. Se analizaron pacientes con hemorroides grado III y IV, en quienes se realizó hemorroidopexia con PPH- 03, desde enero del 2010 hasta diciembre de 2017. Se evaluaron las variables demográficas, las complicaciones y el grado de satisfacción. Se realizó seguimiento postoperatorio semanal, a los 15 días, al mes, a los 6 meses y finalmente un control telefónico. Resultados: Se estudiaron 452 pacientes. La edad media fue de 46 años (rango: 20-75), siendo el 63% (n=291) del sexo masculino. El 84% (n=387) presentaban hemorroides grado III. El índice de complicación fue del 25% (n=115) durante el periodo de seguimiento, en el postoperatorio inmediato, 60 (52%) pacientes presentaron un evento considerado como complicación, y 55 (48%) pacientes presentaron complicaciones mediatas y tardías. Las complicaciones más frecuentes fueron: dolor en 37 (8%) de los pacientes, seguida por proctorragía en 18 casos (4%) y trombosis hemorroidal externa en 15 pacientes (3,3%). (AU)

Background: Hemorrhoidopexy with mechanical suture is an effective technique for hemorrhoidal prolapses grade III and IV. Objective: Describe our experience with this method. Material and methods: A descriptive, retrospective analysis was performed on a prospectively loaded database. Patients with grade III and IV hemorrhoids were analyzed, in whom hemorrhoidopexy was performed with PPH-03, from January 2010 to December 2017. Demographic variables, complications and degree of satisfaction were evaluated. Weekly postoperative follow-up was performed at 15 days, at month, at 6 months and finally a telephone control. Results: 452 patients were studied. The average age was 46 years (range,: 20 - 75), being 63% (n = 291) of the male sex. 84% (n = 387) had grade III hemorrhoids. The complication rate was 25% (n = 115) during the follow-up period, in the immediate postoperative period, 60 (52%). The most frequent complications were: pain in 37 (8%) patients, follow-up by proctorrhagia in 18 cases (4%) and hemorrhoidal thrombosis external in 15 patients (3.3%). (AU)

Hemorroidopexia con sutura mecánica: ¿Qué hemos aprendido? / Hemorrhoidopexy with mechanical suture: What have we learned?

Introducción: El procedimiento ideal para el tratamiento de la Enfermedad Hemorroidal debe aliviar los síntomas, conservar la funcionalidad anorrectal y minimizar las complicaciones. En los Grados III y IV estos objetivos representan un verdadero desafío. Objetivo: Comunicar la experiencia de un equipo quirúrgico con el procedimiento de Hemorroidopexia con sutura mecánica y revisar la evidencia nacional e internacional. Diseño: Análisis retrospectivo sobre una base de datos prospectiva. Material y método: Entre junio de 2007 y diciembre de 2016, fueron intervenidos 135 pacientes con Enfermedad Hemorroidal sintomática Grados III y IV. Se analizan las variables demográficas, indicaciones, técnica, morbilidad a corto y largo plazo. Resultados: 59% de los operados fueron mujeres. La edad promedio con todos los procedimientos fue de 51 años. El 52% de los pacientes presentaban Hemorroides Grado III y el 47% Hemorroides Grado IV. La Hemorroidopexia se realizó como Cirugía ambulatoria en el 17% de los casos. El índice global de complicaciones fue de 11,11%, que agrupamos según Clasificación de Dindo-Clavien. No se registraron complicaciones graves ni mortalidad. Conclusiones: La Hemorroidopexia con sutura mecánica es un procedimiento seguro y efectivo para el tratamiento de los grados avanzados de Enfermedad Hemorroidal. Puede llevarse a cabo en forma ambulatoria. Son esenciales la correcta indicación y capacidad para el manejo de probables complicaciones. (AU)

Background: The best surgical procedure for the Hemorrhoidal Disease must relieve the symptoms, retain anorrectal functionality and minimize complications. At Grades III and IV those aims are a real challege. Objective: To comunicate the one surgical team experience whit stapled Hemhoirrodopexy and to analyse the national and international evidence. Design: Análisis retrospectivo sobre una base de datos prospectiva. Methods: From June 2007 to December 2016 we operated 135 patients to have Hemorrhoidal Disease Grade III and IV. We described demographics dates, indications, and surgical procedure, short and long morbidity. Results: 59% of the patientes was female. In all procedures, de mean age was 50. 52% of the patients was Hemhorroid Disease Grade III and 47% was Grade IV. The Stapled Hemhoirrodopexy was Ambulatory in 17%. The global morbidity was 11,11%. No, have mortality with the surgical procedure. Conclusions: The Stapled Hemohoirodopexy is a safe and effective surgical procedure to treatment of symptomatic Grade III and IV of Hemorrhoidal Disease. It can be carried out as ambulatory surgery. Are clues the right indication and the capacity to resolve complications. (AU)

Early Experience With a Partial Stapled Hemorrhoidopexy for Treating Patients With Grades III–IV Prolapsing Hemorrhoids

PURPOSE: Circular stapled hemorrhoidopexy (CSH) is widely used to treat patients with grades III–IV hemorrhoids because of less pain and short hospital stay. However, this procedure is associated with some complications, such as urge to defecate, anal stenosis, staple line dehiscence, abscess and sepsis. To avoid these complications, surgeons perform a partial stapled hemorrhoidopexy (PSH). The aim of this study is to present our early experience with the PSH. METHODS: We retrospectively reviewed the medical records of 58 patients with hemorrhoids who were treated with a PSH at Busan Hang-Un Hospital from January 2016 to June 2016. A specially designed tri-window anoscope was used, and a purse string suture was made at the mucosae of the protruding hemorrhoids through the window of the anoscope. The hemorrhoidopexy was done by using a circular stapler. RESULTS: Of the 58 patients included in this study, 34 were male and 24 were female patients (mean age, 50.4 years). The mean operation time was 12.4 minutes, and the mean postoperative hospital stay was 3.8 days. Three patients experienced bleeding (5.1%) 5 urinary retention (8.6%) and 5 skin tags (8.6%). Urge to defecate, tenesmus, abscess, rectovaginal fistula, anal stricture, incontinence, and recurrence did not occur. CONCLUSION: PSH is a minimally invasive, feasible, and safe technique for treating patients with grades III–IV hemorrhoids. A PSH, instead of a CSH, can be used to treat certain patients with hemorrhoids.

Long term results after stapled hemorrhoidopexy alone and complemented by excisional hemorrhoidectomy: a retrospective cohort study / Resultados tardios após hemorroidopexia mecânica isolada e complementada por operação excisional

ABSTRACT Background: Stapled hemorrhoidopexy is associated with less postoperative pain and faster recovery. However, it may be associated with a greater risk of symptomatic recurrence. We hypothesized that undertaking a limited surgical excision of hemorrhoid disease after stapling may be a valid approach for selected patients. Aim: To compare long-term results after stapled hemorrhoidopexy with and without complementation with closed excisional technique. Method: In a retrospective uni-institutional cohort study, sixty-five (29 men) patients underwent stapled hemorrhoidopexy and 21 (13 men) underwent stapled hemorrhoidopexy with excision. The same surgeons operated on all cases. Patients underwent stapled hemorrhoidectomy associated with excisional surgery if symptoms attributable to external hemorrhoid piles were observed preoperatively, or if residual prolapse or bulky external disease was observed after the firing of the stapler. A closed excisional diathermy hemorrhoidectomy without vascular ligation was utilized in all complemented cases. All clinical variables were obtained from a questionnaire evaluation obtained through e-mail, telephone interview, or office follow-up. Results: The median duration of postoperative follow-up was 48.5 (6-40) months. Patients with grades 3 and 4 hemorrhoid disease were operated on more frequently using stapled hemorrhoidopexy complemented with excisional technique (95.2% vs. 55.4%, p=0.001). Regarding respectively stapled hemorrhoidopexy and stapled hemorrhoidopexy complemented with excision, there was no difference between the techniques in relation to symptom recurrence (43% and 33%, p=0.45) and median interval between surgery and symptom recurrence (30 (8-84) and 38.8 (8-65) months, p=0.80). Eight (12.3%) patients were re-operated after stapled hemorrhoidopexy and 2 (9.6%), after hemorrhoidopexy with excision (p=0.78). Patient distribution in both groups according to the degree of postoperative satisfaction was similar (p=0.97). Conclusion: Stapled hemorrhoidopexy combined with an excisional technique was effective for more advanced hemorrhoid disease. The combination may have prevented symptomatic recurrence associated to stapled hemorrhoidopexy alone.

RESUMO Racional: A hemorroidopexia com grampeador está significativamente associada a menor dor pós-operatória e recuperação mais rápida. No entanto, há evidência de que possa ter maior taxa de recorrência sintomática. A hipótese é que empreender excisão cirúrgica limitada da doença hemorroidária após o grampeamento pode ser abordagem válida para pacientes selecionados. Objetivo: Avaliar os resultados comparativos a longo prazo após a técnica de grampeamento isolada ou associada à complementação por técnica excisional fechada. Método: Coorte retrospectiva, com 65 (29 homens) pacientes submetidos à hemorroidopexia por grampeamento e 21 (13 homens) a ela complementada por técnica excisional. Os pacientes foram submetidos à complementação do grampeamento se sintomas atribuíveis às hemorróidas externas fossem observados no pré-operatório, ou se prolapso residual ou doença externa volumosa existisse após o disparo do grampeador. A hemorroidectomia excisional fechada por eletrocauterização sem ligadura vascular foi utilizada em todos os casos de complementação. Todas as variáveis ​​clínicas foram obtidos a partir de um questionário eletrônico, entrevista por telefone, ou em consulta. Resultados: A duração média do seguimento pós-operatório foi de 48,5 (6-40) meses. Os pacientes com graus hemorroidários 3 e 4 foram operados com mais frequência usando grampeamento complementado por técnica excisional (95,2% vs. 55,4% - p=0,001). Os pacientes operados por grampeamento sem e com complementação por técnica excisional, não houve diferença entre os grupos quanto a recidiva dos sintomas (43% vs. 33%, p=0,45, respectivamente) ou quanto ao intervalo médio entre a opração e a recorrência dos sintomas (30 (8-84) vs. 38,8 (8-65) meses, p=0,80). Oito (12,3%) pacientes foram reoperados após grampeamento isolado e 2 (9,6%), após grampeamento complementado por técnica excisional (p=0,78). O grau de satisfação pós-operatória foi semelhante entre as técnicas (p=0,97). Conclusão: A hemorroidopexia por grampeamento combinada com técnica excisional foi eficaz para a doença hemorróida mais avançada. A combinação pode ter impedido a recorrência sintomática associada a hemorroidopexia isolada.

Persistent Bleeding Following a Stapled Hemorrhoidopexy

A stapled hemorrhoidopexy (SH) is widely used for treatment of patients with grades III and IV hemorrhoids. The SH is easy to perform, is associated with less pain and allows early return to normal activities. However, complications, whether severe or not, have been reported. Here, we present the case of a female patient with persistent bleeding after a SH. The bleeding was caused by the formation of granulation tissue at the stapler line, diagnosed with sigmoidoscopy, and successfully treated via transanal excision (TAE) under spinal anesthesia. The biopsy showed inflammatory granulation tissue. After the TAE, her symptom was completely gone.

The Significance of Staple Line Height in a Stapled Hemorrhoidopexy

PURPOSE: In 1998, Longo introduced a novel operative technique for hemorrhoids. That technique uses a prolapse and hemorrhoid (PPH) stapler. His results showed minimal pain, short hospital stay, and rapid return to normal social life. However, a higher height of staple line yields less postoperative pain, but more residual piles, and vice versa. This study was designed to find the optimal height of the staple line for a PPH hemorrhoidopexy. METHODS: A total of 65 consecutive patients scheduled for a PPH hemorrhoidopexy on grade II or higher internal hemorrhoids were included in this study. The hemorrhoidopexy was performed as in the literature. A purse-string suture was made 5 cm from the anal verge. Remaining piles were excised immediately after the firing of the PPH stapler. Patients were divided into 2 groups. In group A, the staple line was located above 2 cm proximal to the dentate line, and in group B, it was located below 2 cm proximal to the dentate line. RESULTS: The mean subjective pain score of group A was 2.00, and that of group B was 1.98 (P=0.898). The mean hospital stay of group A was 2.5 days, and that of group B was 2.7 days (P=0.431). Group A returned to normal life in a mean of 7.1 days whereas group B returned to normal life in a mean of 6.8 days (P=0.474). Complications included 6 cases of voiding difficulty, 3 cases of heavy sensation in anus, 1 case of temporary fecal incontinence, and 1 case of anal pain caused by long-standing residual staples. CONCLUSION: No meaningful relationship was found to exist between the staple line height and either pain or the number of days to return to normal life. However, the incidence of residual piles was lower in cases with a low staple line height. Therefore, the level of the staple line should be lower than it is for a conventional Longo procedure.

Hemorroidectomia convencional versus hemorroidopexia mecânica (PPH): estudo retrospectivo de 253 casos / Conventional hemorrhoidectomy versus stapled hemorrhoidopexy (PPH): a retrospective study of 253 patients

O objetivo deste estudo foi rever a experiência do serviço de coloproctologia do HSPM-SP no tratamento cirúrgico da doença hemorroidária. Estudou-se retrospectivamente 253 pacientes portadores de hemorroidas submetidos à cirurgia no período de 10/05/2004 a 31/12/2007. Foram estabelecidos dois grupos: Grupo 1) Pacientes operados pela técnica convencional (212); Grupo 2) Pacientes operados pelo PPH (41). Estudou-se, pela revisão de prontuários, as características epidemiológicas, indicações, resultados e complicações de cada grupo. Entre os 253 pacientes analisados, 170 eram mulheres, com média de idade de 50 anos. O tempo operatório médio foi de 52 minutos para o grupo 1, e 31 minutos para o grupo 2 (p=0,0001). O tempo médio de alta ambulatorial foi de 10 e 6 semanas para o grupo 1 e 2, respectivamente (p=0,021). As complicações totalizaram 28 casos no grupo 1, e 3 casos no grupo 2 (p>0,05). Cerca de 13 casos no grupo 1, e 1 caso no grupo 2 necessitaram de reintervenção cirúrgica. Neste serviço a técnica mais utilizada foi a hemorroidectomia convencional. O método do PPH apresentou tempo operatório mais curto, e recuperação pós-operatória mais breve. Houve uma maior tendência a complicações tardias e recidivas com o grupo de hemorroidectomia convencional, porém sem significância estatística.

The aim of this study was to review the experience of the Coloproctology Department of HSPM-SP in the treatment of hemorrhoids. We have retrospectively studied 253 patients submitted to the surgical treatment of hemorrhoids between 05/10/ 2004 and 12/31/2007. Patients were distributed in groups: Group 1) Conventional Hemorrhoidectomy (212); Group 2) Stapled Hemorrhoidopexy (41). Epidemiology, indications, results and complications were studied based on registers. From 253 patients studied, 170 were women, with a mean age of 50 years. Mean operating time was 52 minutes (25 -120) in group 1 and 31 minutes (20 - 65) in group 2 (p=0.0001). Mean time for ambulatory discharge was 10 and 6 weeks for groups 1 and 2 respectively (p=0.021). The overall complications totalized 28 cases in group 1 and 3 cases in group 2 (p>0,05). In consequence of these complications, 13 cases in group 1, and 1 case in group 2 were submitted to a new surgical procedure. At this Department the most used technique was conventional hemorrhoidectomy. Stapled hemorrhoidopexy was associated with less operating time and a faster functional recovery (early ambulatory discharge). Hemorrhoidectomy was associated with more complications and recurrence, but without statistical significance.

Complications after Stapled Hemorrhoidopexy

PURPOSE: While conventional hemorrhoidectomy is notorious for postoperative pain, stapled hemorrhoidopexy has been reported less painful because it has no anal wound. However, the safety of stapled hemorrhoidopexy is not established completely yet. Therefore, the purpose of this study is to evaluate the safety of stapled hemorrhoidopexy through analyzing the postoperative complications. METHODS: The author analyzed the complications of 63 patients treated with stapled hemorrhoidopexy by reviewing the medical records. All of the operations were performed by one surgeon. RESULTS: There were 39 men and 24 women with a mean age of 47.7 years. The majority of cases were carried out under spinal anesthesia except 4 cases of general anesthesia. The combined operations were performed in 16 cases (25.4%) including skin tag excision, external hemorrhoid excision, and polypectomy. The postoperative complications were 2 cases (3.2%) of rectal stenosis, 1 case (1.6%) of thrombosis, 1 case (1.6%) of abscess, and 1 case (1.6%) of late bleeding. Three patients were needed to rehospitalized and reoperation was needed in 1 case of thrombosis. One case of rectal stenosis was treated easily by manual dilatation. However, the other rectal stenosis was treated by Hega dilatation. CONCLUSION: Complications after stapled hemorrhoidopexy may be different from complications after conventional hemorrhoidectomy. However, most of the complications after stapled hemorrhoidopexy can be avoided by respecting the rectal wall anatomy during the procedure. Therefore, in terms of postoperative complications, the stapled hemorrhoidopexy may be a safe procedure.