Stapled Hemorrhoidopexy Associated With a Higher Rate of Recurrent Prolapses Than Conventional Hemorrhoidectomy

Deborah Brauser

March 19, 2009

March 19, 2009 — Although stapled hemorrhoidopexy (SH) is a safe technique for treating hemorrhoids, it has a significantly higher incidence of recurrences and additional surgeries compared with conventional hemorrhoidectomy (CH), according to results of a meta-analysis study reported in the March issue of the Archives of Surgery.

"Since the introduction of SH, several studies have reported on its safety and efficacy," write Pasquale Giordano, MD, FRCSEd, FRCS, from the Department of Colorectal Surgery at Whipps Cross University Hospital in London, England, and colleagues. "Undoubtedly, SH is quicker to perform, and patients experience less postoperative pain, have a shorter hospital stay, and return to their normal activities earlier."

However, the authors write that most of the initial trials reported on short-term outcomes. "Recent meta-analyses confirmed the short-term benefits of SH but also demonstrated a higher rate of recurrent prolapses, persistent pain, and fecal urgency at 6 months of follow-up. For all these reasons, the definitive role of SH in the treatment of symptomatic hemorrhoids remains to be established."

Study Design

The goal of this study was to examine the long-term outcomes of SH vs CH through an evidence-based meta-analysis. The investigators searched MEDLINE, EMBASE, and Cochrane Library databases for published randomized controlled trials with a minimum clinical follow-up of 12 months. Fifteen articles from 10 countries met the inclusion criteria and were selected. They included a total of 1201 patients, with 597 in the CH group and 604 in the SH group.

Conventional hemorrhoidectomy was defined as a sharp or diathermic excision of hemorrhoidal tissue, anoderm, and perianal skin with or without closure of the ensuing defect. Stapled hemorrhoidopexy was defined as the excision of an annulus of rectal mucosa using a dedicated transanal circular stapler.

Three of the chosen studies examined only third-degree hemorrhoids (58 treated with SH vs 51 treated with CH), 3 others analyzed only fourth-degree hemorrhoids (65 SH vs 72 CH), 1 study looked at both degrees, and the remaining studies either involved patients with different degrees or the degree was not specified. Only 14 of the studies reported the incidence of recurrences at the long-term follow-up, which ranged from 12 to 84 months.

A specifically designed data form was used to collect all relevant information, including details of the experimental design, patient demographics, technical aspects, outcome measures, and complications. This data collection was performed independently by 2 researchers and then compared.

Primary outcome measures of this study were hemorrhoidal recurrences in terms of recurrent bleeding or prolapse and need for further interventions. Secondary outcomes were pain at defecation, anal stenosis, fecal urgency, fecal incontinence, and patient satisfaction.

Higher Prolapse Rate After SH

Overall outcomes at a minimum of 1 year showed a significantly higher rate of prolapse recurrences after SH vs CH (14 studies, 1063 patients; odds ratio [OR], 5.5; P < .001). In addition, these patients were more likely to undergo further treatment to correct recurrent prolapses compared with those in the CH group (10 studies, 824 patients; OR, 1.9; P = .02).

The 3 studies that looked only at third-degree hemorrhoids showed a recurrence rate of 20.7% for SH and 3.9% for CH (OR, 10.4; P < .003). The 3 that included only fourth-degree hemorrhoids showed an overall recurrence rate of 20.0% for SH and no recurrences for CH (OR, trend to infinite; P < .001). The other 9 studies, which did not specify degree, also showed a significant difference in recurrences between SH and CH patients (OR, 3.1; P < 0.02).

In the 9 studies that commented on pain at defecation atlong-term follow-up, results were not statistically significant (560 patients; OR, 0.4; P = .35). In 2 studies (n = 131), 13.8% of the patients who underwent SH experienced tenesmus at 1 year, compared with none of those in the CH group (OR, trend to infinite; P < .001).

In 5 studies that presented data on anal manometry, no differences were found between the groups for bleeding at defecation, anal stenosis, fecal urgency, and fecal incontinence. In 5 of the 6 studies that assessed patient satisfaction at 1 year, similar results were found between the 2 groups. However, in the sixth study, patient satisfaction was greater after SH. The study authors write, "This result is possibly explained by the fact that the early postoperative benefits of SH could overcome the higher incidence rate of late symptoms."

Some Limitations

Limitations of this meta-analysis include the wide variance of 0% to 53.3% between recurrence incidences among the studies. "Although there is no explanation for this result, it is possible that a number of factors may influence the recurrence rate after SH," write the study authors. "Technical characteristics such as the placement of the purse string, the level of the staple line, and the completeness of the mucosectomy ring may influence the outcome." Information on these items was not available in any of the studies analyzed.

The number of centers involved also differed greatly (from 1 to 17), possibly creating outcome differences. In addition, only 5 of the studies looked at the degree of hemorrhoid treated and the related outcome.

"CH and SH are safe procedures with similar long-term morbidities; however, SH carries a significantly higher incidence of recurrence, additional operations, and tenesmus compared with CH," the study authors conclude. "We believe that the results of this review finally provide definite information on the long-term outcome of SH. It will ultimately be the patient's choice whether to accept a higher recurrence rate to take advantage of the short-term benefits of SH."

The authors have disclosed no relevant financial relationships.

Arch Surg. 2009;144(3):266–272.

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