Abstract
Circular stapled transanal hemorrhoidopexy (STH) was first introduced by A. Longo for the correction of internal mucosal prolapse and obstructed defecation and in 1998, was proposed as alternative to conventional excisional hemorrhoidectomy. More recently, stapled transanal rectal resection (STARR) has gradually gained popularity, as the Longo procedure, in the treatment of hemorrhoids. The aim of our study was to evaluate the usefulness of STARR as alternative to STH in patients with grade III (n=218, 68.1%) and IV (n=102, 31.9%) hemorrhoids. A group of 320 consecutive patients (median age=51 years; range=16-85) underwent STH (n=281) or STARR (n=39) procedure. The rate of postoperative bleeding (53.8% vs. 74.4%, p<0.01) was significantly reduced in patients who underwent STARR procedure, which required a longer (45±22 vs. 26±11 min, p<0.01) operative time. There were no differences between groups with regard to use of painkillers, postoperative pain intensity, short- (three months) and long-term (one and three years) residual pain, soiling, incontinence and urgency. Patients treated with the STARR procedure had lower recurrence rate of hemorrhoids and a lower incidence of prolapse, both at one year (none vs. 1.4%, p=0.593 and 2.6% vs. 5.3%, p=0.396, respectively) and at two years (none vs. 6.8%, p=0.078 and none vs. 13.2%, p=0.012, respectively). The one-year (9.0±1.8 vs. 9.4±0.7, p=0.171) and two-year (9.6±0.8 vs. 9.1±1.7, p=0.072) general satisfaction was similar but higher in STARR patients than in the STH group. In conclusion, according to our preliminary results, the STARR procedure leads to a lower incidence of complications and recurrences and should be considered for patients with grade III or IV hemorrhoids previously selected for stapled hemorrhoidectomy, as a promising alternative to STH.
- Prolapsed hemorrhoids
- circular stapled hemorrhoidectomy
- Longo procedure
- transanal stapled rectal resection
- STARR procedure
Circular stapled transanal hemorrhoidopexy (STH) was first introduced by A. Longo for the correction of internal mucosal prolapse and obstructed defecation and later, in 1998, was proposed as alternative to conventional excisional hemorrhoidectomy (1). This technique offers several advantages compared to Milligan-Morgan and Ferguson techniques, such as reduced operative time and postoperative pain, although an increase in the recurrence of hemorrhoids has been observed (2-5). Stapled transanal rectal resection (STARR) was originally proposed to treat patients with rectocele and obstructed defecation, but then it has gradually gained popularity, as the Longo procedure, in the treatment of hemorrhoids (6). The larger amount of rectal wall ablated might help obtain a lower incidence of hemorrhoids recurrence. Despite short operative time and hospital stay, low postoperative pain and early return to work, high recurrence rate (5-6% at one year) and rare, but potentially severe, complications are reported in patients who underwent STH (7-9). Thus, it has been suggested that submucosal excision and the traditional Milligan-Morgan hemorrhoidectomy should be considered as the main procedure for grade III and IV hemorrhoids (10).
The aim of our study was to evaluate the usefulness of the STARR procedure as alternative to STH in patients with grade III and IV hemorrhoids. The primary end-point of the present study was to assess the recurrence rate after surgery and secondary end-points were to compare the use of painkillers, complications onset and general satisfaction of the patients.
Patients and Methods
Study population. A group of 320 consecutive patients with symptomatic grade III (n=218, 68.1%) and IV (n=102, 31.9%) hemorrhoids were prospectively enrolled in the study. Written informed consent was obtained from all participants. There were 131 (40.9%) women and 189 (59.1%) men with an overall median age of 51 years (range, 16-85 years). Exclusion criteria were previous anorectal surgery or anorectal diseases other than hemorrhoids. Two hundred and eighty-one (87.8%) patients underwent the STH procedure and 39 (12.2%) sex- and age-matched patients underwent the STARR procedure. The characteristics of each group, including weight, height and the reported main preoperative symptoms are shown in Table I.
All patients were assessed postoperatively with an ad hoc questionnaire. For the quantification of pain, a visual analogue scale (VAS), which provides 11 possible values (from zero to 10), was used. The use of painkillers (paracetamol 500 mg plus codeine 30 mg, with maximum dosage 1,500/90 mg/day; ketorolac 30 mg, with a maximum dosage 60 mg/day; morphine 10 mg/day) was reported as number of doses needed. Other symptoms reported in the questionnaire were soiling, incontinence and general satisfaction (0-10 scale). The presence of prolapse, stenosis or recurrence of hemorrhoids at physical examination was also reported. All patients were re-evaluated periodically, up to a maximum of two years after surgery.
Surgical procedure. All operations were performed by or under the direct supervision of the same consultant surgeon (S.S.) and were usually carried-out with the patient in lithotomy position under spinal anesthesia (n=299, 93.4%) or general anesthesia (n=21, 6.6%). In all STH procedures an anal dilator and a 2-0 polypropylene purse string suture, which begins and ends at the site of maximum prolapse about 3-4 cm above the dentate line, were used. The fully opened PPH (procedure for prolapse and hemorrhoids device) circular stapler (PPH 01 or PPH 03, Ethicon Endo-Surgery, Cincinnati, OH, USA) was inserted and both ends of the purse string suture were extracted. Traction was maintained to enclose a substantial amount of rectal tissue in the stapler. Polyglactin 910 sutures (usually 2-0) were used to control any bleeding. The STARR procedure consisted of a double transanal rectal resection, performed by using three points for each resection to remove maximum amount of tissue. Each patient remained hospitalized for one day, to treat postoperative pain and any possible bleeding complication.
Statistical analysis. Continuous variables are reported as mean±standard deviation (SD), median (range) or frequency (%) distribution, to describe baseline characteristics and results. Comparisons between groups were obtained using the Student's t-test or the Mann-Whitney U-test. Chi-squared (χ2) test, if all frequencies were equal or greater than five, or Fisher exact probability test were used to analyze dichotomous variables and to compare short- and long-term results. The differences were considered significant at a p-value <0.01. The software used was Statistica (StatSoft, Tulsa, OK, USA).
Results
The age of the patients, male-to-female ratio and the incidence of the main symptoms did not differ significantly between groups (Table I). The median duration of symptoms was 60 months (range=1-360) and 48 months (range=1-480) among STH and STARR patients, respectively. Table II displays the intra- and postoperative parameters considered for each group and the long-term (one- and two-year) results. Overall, the operative time was 28±14 min per patient and the median hospital stay was one day in both groups. The median operative time was significantly shorter for the STH group of patients (25 min; range=15-120) than that of the STARR group (40 min; range=25-150). Postoperative bleeding was common and significantly more frequent in patients who underwent the STH procedure (74.4% vs. 53.8%, p=0.007); only three (0.9%) patients required blood transfusion and none underwent reoperation for hemorrhage control. There were no differences as regards the use of painkillers (STH vs. STARR) both for intravenous (10.7% vs. 2.6%, p=1.148) or oral administration, although STH patients used more frequently ketorolac (58.5% vs. 31.0%, p=0.006) and less frequently paracetamol plus codeine (39.9% vs. 65.5%, p=0.009) than those of the other group. Morphine was administered only in four (1.2%) patients. The postoperative pain intensity on day one, three and eight did not differ significantly between groups. The time to return to normal activity in both groups was one week. The residual pain, soiling, incontinence and urgency at three months (STH vs. STARR) were 28.8% vs. 43.6%, (p=0.061), 0.3% vs. 3.4% (p=0.229), 0.3% vs. none (p=0.878) and 0.7% vs. none (p=0.771), respectively. Patients treated with the STARR procedure had a lower recurrence rate of hemorrhoids and a lower incidence of prolapse, both at one year (none vs. 1.4%, p=0.593 and 2.6% vs. 5.3%, p=0.396, respectively) and at two years (none vs. 6.8%, p=0.078 and none vs. 13.2%, p=0.012, respectively). The one-year (9.0±1.8 vs. 9.4±0.7, p=0.171) and two-year (9.6±0.8 vs. 9.1±1.7, p=0.072) general satisfaction was similar but higher in STARR patients than in the STH group.
Discussion
Symptomatic hemorrhoids are the clinical manifestation of the disruption of normal anal cushions from their suspensory ligaments (11). Grade III emorrhoidal prolapse remains the best indication for stapled hemorrhoidopexy despite this treatment leads to an increased risk of bleeding and recurrence (7). Patients with grade IV hemorrhoids are most often treated with traditional non-stapled techniques and several studies report a high incidence of complications and recurrence when STH is used (8, 12, 13). Different types of devices have been used, including PPH, EEA (Codiven; Manfield, MA, USA) and Ligasure vessel sealing system (Valleylab; Boulder, CO, USA), and all are generally considered superior to conventional hemorrhoidectomy for different reasons (14-16). STH compared to Milligan-Morgan and Ferguson hemorrhoidectomy presents several advantages, including a reduction in operative time, postoperative pain, duration of hospital stay and time to return to normal activities (17, 18). A systematic review confirmed these data (19). According to another meta-analysis the recurrence rate after STH is higher (5.6% vs. 1%, p=0.02) compared to conventional hemorrhoidectomy but the overall incidence of early and late recurrent symptoms is 24.8% vs. 31.7% (p=0.08) and 25.8% vs. 18.7% (p=0.07), respectively, and, thus, similar for both techniques (20). However, SRH causes less postoperative bleeding and other minor complications. Recently, a new type of stapling device, named Contour Transtar (Ethicon Endo-Surgery; Cincinnati, OH, USA) was used in patients with obstructive defecation syndrome (21). It was designed for tailoring the correction of rectal prolapse but it has not yet been used in the treatment of hemorrhoids. With the aim of reducing long-term complications of STH, the STARR procedure for advanced hemorrhoids has been proposed, providing with several advantages compared with STH, especially in the hemorrhoids associated with rectal internal mucosal prolapse (6). In a multicentric study, postoperative rectal bleeding occurred only in 11% of patients who underwent the STARR procedure for obstructed defecation (22). The PPH device does not interrupt the vascular supply to the hemorrhoids; its use may usually contribute to reduce bleeding (8). In our series, no patients of the STARR group and only two (0.7%) of the STH group complain of persisting rectal pain, while this is a late complication reported in other studies (23, 24). Residual prolapse and hemorrhoids recurrence were not observed in the STARR group but represented a late complication of STH in 37 (13.2%) and 19 (6.8%) patients, respectively. We hypothesize that the double transanal resection obtains a larger amount of tissue and does not lead to insufficient resection. In both groups we did not observe other complications, such as complete rectal obliteration, rectal pocket, retropneumoperitoneum, pelvic sepsis and rectal perforation, as reported elsewhere (8).
Main preoperative parameters (mean±standard deviation).
Intra- and postoperative data (mean±standard deviation).
In conclusion, according to our preliminary results, the STARR procedure gives results similar to those obtained with STH but with a lower incidence of complications and recurrences. Thus, it should be considered for patients with grade III or IV hemorrhoids previously selected for stapled hemorrhoidectomy, as a promising alternative to STH.
- Received August 4, 2014.
- Revision received September 15, 2014.
- Accepted September 22, 2014.
- Copyright © 2014 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved
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