Tech Coloproctol (2015) 19:321–322 DOI 10.1007/s10151-015-1298-1
CORRESPONDENCE
Recurrence after stapled haemorrhoidopexy D. Mascagni1 • G. Naldini2 • A. Stuto3 • F. Da Pozzo4 • A. Bianco2 D. Pironi1 • A. Panarese1
•
Received: 1 September 2014 / Accepted: 2 October 2014 / Published online: 7 April 2015 Ó Springer-Verlag Italia Srl 2015
Dear Sir, The surgical procedure of stapled haemorrhoidopexy is now considered safe, and its reliability is improving with experience and technical upgrading. Compared to conventional procedures, the short-term advantages of stapled haemorrhoidopexy include less postoperative pain, faster recovery and healing, whereas the disadvantages of the procedure in the long term include an increased possibility of recurrent prolapse. The percentage of symptomatic prolapse after stapled procedures widely varies in the several clinical trials described in the literature, ranging between 2 and 53.3 % [1]. Many short- and long-term complications of the different treatments for haemorrhoids (conventional, stapled or realized with different new devices) have been reported in the literature [2]. Less evidence is available about how to minimize these undesirable effects of stapling procedures, and there are no studies that describe and classify recurrences and the strategies to deal with them. We performed a retrospective study on 69 patients with recurrent prolapse after stapled haemorrhoidopexy [58 patients treated with a single-stapled procedure and 11 with
& D. Pironi [email protected] 1
Department of Surgical Sciences, Sapienza University of Rome, V.le Regina Elena no. 324, 00161 Rome, Italy
2
Proctological and Perineal Surgical Unit, University of Pisa, Pisa, Italy
3
Department of Gynecological Surgery and Urology, University of Pordenone, Pordenone, Italy
4
Department of General Surgery, University of Trieste, Trieste, Italy
a double-stapled procedure for prolapse and haemorrhoids (DSPPH)] who underwent re-intervention for recurrence. Prolapse over half of the circular anal dilator (CAD) is usually treated with a double stapling technique [3]. Thirty-five patients were female, and 34 were male. The mean age was 50 years (range 25–74 years). The follow-up was performed in the outpatient clinic at 1 week, 4 weeks and 6 months after surgery and yearly thereafter. The mean time until recurrence was 18 months (range 2–42 months) in the 58 patients, who had undergone a procedure for prolapse and haemorrhoids (PPH), and 12 months (range 2–42 months) in those who had undergone a DSPPH. The clinical onset of recurrence and the operations chosen are shown in Table 1. In the group of patients treated with PPH or DSPPH, bleeding requiring surgical revision occurred in one patient. Minor bleeding, managed with a local haemostatic device, was reported by one patient. In the patients treated with surgical excision, instead, bleeding occurred in one patient and required surgical revision. Urgency (n = 2) and anal pain (n = 2), which occurred in patients in both groups, spontaneously disappeared after surgery. In the patients who underwent surgical excision combined with PPH, no bleeding, urgency or persisting anal pain occurred. The mean follow-up after reoperative surgery lasted 40 months (range 23–96 months). No cases of second recurrence occurred. In the case of a mobile prolapse, this may be resected with stapler (PPH or DSPPH, depending on the amount of the prolapse that needs to be resected). On the contrary, in the case of a fixed prolapse, one or two piles, the choice should be surgical excision. In case of more than three multiple piles (C3), transrectal resection with a stapler (PPH or DSPPH) may be used. A PPH combined with Milligan–Morgan haemorrhoidectomy should be applied in
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Tech Coloproctol (2015) 19:321–322
Table 1 Intraoperative findings and operation performed Intraoperative findings
Post-previous PPH ? (n = 58)
Prolapsed haemorrhoids with one pile or multiple piles B3
30 ? Surgical excision
6 ? Surgical excision
Congested haemorrhoids
4 ? Surgical excision
2 ? Surgical excision
Mobile prolapse
12 ? PPH
1 ? PPH
6 ? DSPPH
1 ? DSPPH
6 ? PPH ? surgical excision
1 ? PPH ? surgical excision
Mobile prolapse ? thrombosed haemorrhoids
Post-previous DSPPH ? (n = 11)
PPH procedure for prolapse and haemorrhoids DSPPH double-stapled procedure for prolapse and haemorrhoids
case of a mobile prolapse with some residual haemorrhoidal tissue. The unsatisfactory results can be due to incorrect indications (grade 4 haemorrhoids with a predominant external, fibrous component), technical inaccuracies during the surgical procedure and insufficient prolapse correction. Thus, intraoperative evaluation is crucial and so is knowledge of all the surgical options, because this permits the surgeon to decide, without prejudice, whether surgical excision or a repeat stapled procedure is more suitable. A second surgical excision or a repeat stapled haemorrhoidopexy presents the same difficulties as a primary operation. The previous anastomosis (usually included in the second resection) is not an obstacle to the realization of the purse string for the second stapled procedure. Our experience demonstrated that after 6 months a repeat stapled procedure can be safely performed. No serious complications were reported while Brusciano et al. [4] reported a high bleeding and soiling rate in patients who had undergone reintervention. A primary operation tailored to the effective amount of the prolapse (using a single- or double-stapled technique), devices with larger case, parachute technique or with an immediate, intraoperative correction of the persistent prolapse or excision of a residual pile make it possible to avoid
123
or minimize the risk of recurrent prolapse. Residual or recurrent prolapse can be due to either an incorrect indication for surgery, an incorrectly performed procedure or an insufficient pull of the prolapsed tissue during prior intervention [5]. Conflict of interest
None.
References 1. Panarese A, Pironi D, Vendettuoli M et al (2012) Stapled and conventional Milligan–Morgan haemorrhoidectomy: different solutions for different targets. Int J Colorectal Dis 27:483–487 2. Ravo B, Amato A, Bianco V et al (2002) Complications after stapled hemorrhoidectomy: Can they be prevented? Tech Coloproctol 6:83–88 3. Naldini G, Martellucci J, Talento P, Caviglia A, Moraldi L, Rossi M (2009) New approach to large haemorrhoidal prolapse: double stapled haemorrhoidopexy. Int J Colorectal Dis 24:1383–1387 4. Brusciano L, Ayabaca SM, Pescatori M et al (2004) Reinterventions after complicated of failed stapled hemorrhoidopexy. Dis Colon Rectum 47:1846–1851 5. Boccasanta P, Stuto A, Naldini G, Caviglia A, Carriero A (2006) Opinions and facts on reinterventions after complicated or failed stapled hemorrhoidectomy. Dis Colon Rectum 49:690–691 author reply 691–693
CORRESPONDENCE
Recurrence after stapled haemorrhoidopexy D. Mascagni1 • G. Naldini2 • A. Stuto3 • F. Da Pozzo4 • A. Bianco2 D. Pironi1 • A. Panarese1
•
Received: 1 September 2014 / Accepted: 2 October 2014 / Published online: 7 April 2015 Ó Springer-Verlag Italia Srl 2015
Dear Sir, The surgical procedure of stapled haemorrhoidopexy is now considered safe, and its reliability is improving with experience and technical upgrading. Compared to conventional procedures, the short-term advantages of stapled haemorrhoidopexy include less postoperative pain, faster recovery and healing, whereas the disadvantages of the procedure in the long term include an increased possibility of recurrent prolapse. The percentage of symptomatic prolapse after stapled procedures widely varies in the several clinical trials described in the literature, ranging between 2 and 53.3 % [1]. Many short- and long-term complications of the different treatments for haemorrhoids (conventional, stapled or realized with different new devices) have been reported in the literature [2]. Less evidence is available about how to minimize these undesirable effects of stapling procedures, and there are no studies that describe and classify recurrences and the strategies to deal with them. We performed a retrospective study on 69 patients with recurrent prolapse after stapled haemorrhoidopexy [58 patients treated with a single-stapled procedure and 11 with
& D. Pironi [email protected] 1
Department of Surgical Sciences, Sapienza University of Rome, V.le Regina Elena no. 324, 00161 Rome, Italy
2
Proctological and Perineal Surgical Unit, University of Pisa, Pisa, Italy
3
Department of Gynecological Surgery and Urology, University of Pordenone, Pordenone, Italy
4
Department of General Surgery, University of Trieste, Trieste, Italy
a double-stapled procedure for prolapse and haemorrhoids (DSPPH)] who underwent re-intervention for recurrence. Prolapse over half of the circular anal dilator (CAD) is usually treated with a double stapling technique [3]. Thirty-five patients were female, and 34 were male. The mean age was 50 years (range 25–74 years). The follow-up was performed in the outpatient clinic at 1 week, 4 weeks and 6 months after surgery and yearly thereafter. The mean time until recurrence was 18 months (range 2–42 months) in the 58 patients, who had undergone a procedure for prolapse and haemorrhoids (PPH), and 12 months (range 2–42 months) in those who had undergone a DSPPH. The clinical onset of recurrence and the operations chosen are shown in Table 1. In the group of patients treated with PPH or DSPPH, bleeding requiring surgical revision occurred in one patient. Minor bleeding, managed with a local haemostatic device, was reported by one patient. In the patients treated with surgical excision, instead, bleeding occurred in one patient and required surgical revision. Urgency (n = 2) and anal pain (n = 2), which occurred in patients in both groups, spontaneously disappeared after surgery. In the patients who underwent surgical excision combined with PPH, no bleeding, urgency or persisting anal pain occurred. The mean follow-up after reoperative surgery lasted 40 months (range 23–96 months). No cases of second recurrence occurred. In the case of a mobile prolapse, this may be resected with stapler (PPH or DSPPH, depending on the amount of the prolapse that needs to be resected). On the contrary, in the case of a fixed prolapse, one or two piles, the choice should be surgical excision. In case of more than three multiple piles (C3), transrectal resection with a stapler (PPH or DSPPH) may be used. A PPH combined with Milligan–Morgan haemorrhoidectomy should be applied in
123
322
Tech Coloproctol (2015) 19:321–322
Table 1 Intraoperative findings and operation performed Intraoperative findings
Post-previous PPH ? (n = 58)
Prolapsed haemorrhoids with one pile or multiple piles B3
30 ? Surgical excision
6 ? Surgical excision
Congested haemorrhoids
4 ? Surgical excision
2 ? Surgical excision
Mobile prolapse
12 ? PPH
1 ? PPH
6 ? DSPPH
1 ? DSPPH
6 ? PPH ? surgical excision
1 ? PPH ? surgical excision
Mobile prolapse ? thrombosed haemorrhoids
Post-previous DSPPH ? (n = 11)
PPH procedure for prolapse and haemorrhoids DSPPH double-stapled procedure for prolapse and haemorrhoids
case of a mobile prolapse with some residual haemorrhoidal tissue. The unsatisfactory results can be due to incorrect indications (grade 4 haemorrhoids with a predominant external, fibrous component), technical inaccuracies during the surgical procedure and insufficient prolapse correction. Thus, intraoperative evaluation is crucial and so is knowledge of all the surgical options, because this permits the surgeon to decide, without prejudice, whether surgical excision or a repeat stapled procedure is more suitable. A second surgical excision or a repeat stapled haemorrhoidopexy presents the same difficulties as a primary operation. The previous anastomosis (usually included in the second resection) is not an obstacle to the realization of the purse string for the second stapled procedure. Our experience demonstrated that after 6 months a repeat stapled procedure can be safely performed. No serious complications were reported while Brusciano et al. [4] reported a high bleeding and soiling rate in patients who had undergone reintervention. A primary operation tailored to the effective amount of the prolapse (using a single- or double-stapled technique), devices with larger case, parachute technique or with an immediate, intraoperative correction of the persistent prolapse or excision of a residual pile make it possible to avoid
123
or minimize the risk of recurrent prolapse. Residual or recurrent prolapse can be due to either an incorrect indication for surgery, an incorrectly performed procedure or an insufficient pull of the prolapsed tissue during prior intervention [5]. Conflict of interest
None.
References 1. Panarese A, Pironi D, Vendettuoli M et al (2012) Stapled and conventional Milligan–Morgan haemorrhoidectomy: different solutions for different targets. Int J Colorectal Dis 27:483–487 2. Ravo B, Amato A, Bianco V et al (2002) Complications after stapled hemorrhoidectomy: Can they be prevented? Tech Coloproctol 6:83–88 3. Naldini G, Martellucci J, Talento P, Caviglia A, Moraldi L, Rossi M (2009) New approach to large haemorrhoidal prolapse: double stapled haemorrhoidopexy. Int J Colorectal Dis 24:1383–1387 4. Brusciano L, Ayabaca SM, Pescatori M et al (2004) Reinterventions after complicated of failed stapled hemorrhoidopexy. Dis Colon Rectum 47:1846–1851 5. Boccasanta P, Stuto A, Naldini G, Caviglia A, Carriero A (2006) Opinions and facts on reinterventions after complicated or failed stapled hemorrhoidectomy. Dis Colon Rectum 49:690–691 author reply 691–693
