Reinterventions for specific technique-related complications of stapled haemorrhoidopexy (SH): a critical appraisal.

INTRODUCTION: Stapled haemorrhoidopexy (SH) is an attractive alternative to conventional haemorrhoidectomy (CH) because of reduced pain and earlier return to normal activities. However, complication rates are as high as 31%. Although some complications are similar to CH, most are specifically technique-related. In this prospective audit, we report our experience with the management of some of these complications. METHODS: Data on patients undergoing SH at our unit or referred to us are prospectively entered in a database. The onset or duration of specific SH-related complications as well as reinterventions for failed or complicated SH was recorded. RESULTS: From 1/03 to 10/07, 110 patients underwent SH, while 17 patients were referred after complicated/failed SH. Overall early and late complication rates after SH were 12.7% and 27.2%, respectively. Overall reintervention rate was 9.1%. Among the referred SH-group, one patient underwent Hartmann's procedure because of rectal perforation. The remaining 16 patients experienced at least one of the following: recurrence, urgency, frequency, severe persistent anal pain, colicky abdominal pain, anal fissure and stenosis. Four patients underwent CH with regular postoperative recovery. Two patients underwent exploration under anaesthesia because of persisting pain. One patient underwent anoplasty. CONCLUSIONS: SH presents unusual and challenging complications. Abuses should be minimized and longer-term studies are needed to further clarify its role.

Treatment of hemorrhoids in day surgery: stapled hemorrhoidopexy vs Milligan-Morgan hemorrhoidectomy.

BACKGROUND: Recently, it has been demonstrated that surgical treatment of hemorrhoids in a day-care basis is possible and safe. The aim of this study was to compare the Longo stapled hemorrhoidopexy (SH) and the Milligan-Morgan hemorrhoidectomy (MMH). METHODS: One hundred seventy one patients (95 cases in SH group and 76 cases in MMH group) entered the study: 83 cases were III degree hemorrhoids, 88 IV degree. A priori and a post hoc power analysis were performed. Results, prospectively collected, were compared using chi squared test and student t test. Visual analog scale was used for pain evaluation. Postoperative pain, duration of pain, wound secretion, bleeding, resumption of a normal lifestyle, and postoperative complication were evaluated. RESULTS: Surgical time was 28.41+/-10.78 for MMH and 28.30+/-13.28 min in SH (P=0.94). Postoperative pain was not different between MMH and SH during the first two postoperative days (4.73+/-2.91 vs 5.1+/-3.048; P=0.4), during the following 6 days, patients treated with SH had less pain (4.63+/-2.04 in MMH vs 3.60+/-2.35 in SH; P=0.006). In the SH group, seven patients needed further hospital stay for complicated course. SH showed higher incidence of anal fissure compared with MMH (6.3% vs 0%; P=0.025) but no differences in urinary retention, anal stricture, urgency, or anal hemorrhage. CONCLUSIONS: This study confirms that SH is associated with less postoperative pain and shorter postoperative symptoms, compared with MMH. SH may be a viable addition to the therapy for hemorrhoids with some advantages in early postoperative pain and some disadvantages in postoperative complications and costs.

Stapled hemorrhoidopexy: a prospective study from pathology to clinical outcome.

Stapled hemorrhoidopexy is widely accepted to treat hemorrhoids, but serious complications have been reported. In this prospective audit, we correlated clinical outcome with pathological findings. From January 2003 to April 2007, 94 patients underwent hemorrhoidopexy. Macroscopic appearance of the specimen (shape, size, and depth) was recorded. Microscopically, the presence of columnar, transitional, and squamous epithelium, the involvement of circular/longitudinal smooth muscle, and features of mucosal prolapse were assessed. Clinical outcome was evaluated by a validated questionnaire. Postoperative pain, secretion, and bleeding durations were 12.7+/-10.6, 5.6+/-9.6, and 6.3+/-8.4 days. Patient's return to work averaged 16.7+/-10.7 days. Fissure, skin tags, and anal strictures were observed in 23.4%. Seven patients experienced pain for a significantly longer period of time. All specimens contained columnar mucosa, but 29.8% contained columnar and transitional epithelium and 12.8% contained columnar, anal transitional, and stratified squamous epithelium. Smooth muscle was observed in 62.7%. Pain was significantly increased if transitional epithelium was present in the specimen. No correlation or differences were observed if smooth muscle was present, although postoperative bleeding was more frequent. Hemorrhoidopexy is safe and effective. The specimen should always be sent for pathology examination. Only columnar epithelium should be present and, although the presence of smooth muscle does not influence the outcome in terms of functional results, its presence may play a role in postoperative bleeding.

Laparoscopic suture repair of a perforated gastric ulcer in a severely cirrhotic patient with portal hypertension: first case report.

BACKGROUND: Open digestive surgery in cirrhotic patients is associated with high morbidity and mortality. Laparoscopy in this setting has the potential to reduce postoperative complications. Laparoscopic treatment of a perforated gastric ulcer in a severely cirrhotic patient with portal hypertension is herein described. METHODS: A 75-year-old woman affected by cirrhosis of the liver (Child class C) and chronic gastric ulcer presented with acute abdominal pain. The diagnosis of perforation was made with plain films of the abdomen and computed tomography. Diagnostic laparoscopy showed intense peritonitis due to a perforated ulcer of the anterior gastric wall, 2 cm proximal to the pylorus. Suture closure and placement of an omental patch were performed laparoscopically. RESULTS: Postoperative recovery was complicated by a minor leak of the gastric suture, managed by total parenteral nutrition. Closure of the gastric wound was demonstrated by Gastrografin studies on the 10th postoperative day. The patient was discharged on the 16th postoperative day. At 3-months follow-up, the patient is alive and free of gastric disease.