8/6/2019 Hemorhoidectomy Poster

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Stapled Hemorrhoidopexy; Outcome AssessmentThomas Mazza MD, Scott D. Goldstein MD, Gerald Isenberg MD,

James Fitzgerald MD, Andrew Richards MD*, Brian Delong MD*,Larry Sollenberger MD*

Introduction

Hemorrhoids have long been a problem in healthcare affecting morethan 1 million Americans per year.It has been estimated that over a 3 year period approximately 4.4%of the US population will have symptoms attributed to hemorrhoids.Treatments for hemorrhoids vary from lifestyle modifications totopical therapy to surgical excision.Recently a new approach to treatment has entered the surgicalrealm; the so-called procedure for prolapsed hemorrhoids (PPH).

Anatomy Overview

Vascular cushionsHelp protect anal canal during defecationBlood supplied primarily from superior hemorrhoidal arteryUsual bundles located in three distinct areasIncreased intraabdominal pressure may cause backflow of venousblood

View from prone position

Community Practice Outcomes

We provide a retrospective analysis of theexperience with PPH during a 3 year periodin a 3 physician private colorectal practiceand a 1 year period in an academic trainingprogram for colon and rectal surgery

Chart review identified 7 procedurescompleted in 2002, 43 in 2003, and 88 in2004. Another 14 procedures werecompleted during the 2005-2006 academicyear (n=152).

Indications for surgery included:

Prolapse grade II or III: 152

Bleeding: 129

Discomfort: 47Anal hygiene: 19

Male to Female ratio: 78 : 74

Age distribution

MalesRange: 28-76 yrs

20-29: 130-39: 840-49: 2850-59: 2160-69: 1370-79: 7

Mean: 52.1 y/o

FemalesRange: 23-86 yrs

20-29: 230-39: 8

40-49: 2750-59: 1160-69: 1070-79: 13>80: 3

Mean: 54.2 y/o

Type of anesthesia

General: 19

Monitored sedation: 131

Associated procedures during PPH

Colonoscopy: 34Removal of skin tag: 29External hemorrhoidectomy: 4

Lateral sphincterotomy: 3Ferguson Hemorrhoidectomy: 1

Delayed procedures

External hemorrhoidectomy: 5Control of bleeding: 4Ferguson hemorrhoidectomy for

recurrence: 3Removal of skin tag: 2Banding: 2

Lateral sphincterotomy: 1Dilation: 1

0

5

10

15

20

25

30

20-

29yrs

33-

39yrs

40-

49yrs

50-

59yrs

60-

69yrs

70-

79yrs

>80

Male Female

Age Distribution

88%

12%

General

MAC

Anesthesia

Type of hospital visit

Out patient: 133

Same day admission: 11

In patient: 8

Complications

Bleeding: 33

Unexpected admission:6

Urinary retention: 5

Impaction: 3

Abscess: 2

Total of 78 patientscontacted for survey

Degree of pain postoperatively

Extreme:12.8% (n=10)

Moderate:38.5%(30)

Little: 35.9%(28)

None:12.8% (10)

Pain comparison toexpectations

Less thanexpected: 67.9%(53)

More thanexpected: 11.5%(9)

As expected:20.5%

(16)

Retrospective survey of

patients experiences

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Non

e

Little

Mod

erat

e

Extr

eme

Post Op pain assessment

Status of symptoms

Completelyresolved:

52.6%(41)Significantimprovement:

38.5%(30)Little improvement:

6.4%(5)Recurrentsymptoms: 2.6%(2)

Average length of time toreturn to normal function

3 weeks:

11.5% (9)

53%

6%3%

38%

Completely resolved

Significant Improvement

Litt le Improvement

Recurrence

Status of Symptoms

Degree of satisfaction withprocedureExcellent: 64.1%(50)Good: 21.8%(17)Satisfied: 7.7% (6)Unsatisfied: 6.4% (5)

Would recommend procedure to familyor friends with similar symptoms.

Yes: 89.7% (70)

No: 2.6% (2 )

Undecided: 7.7% (6)

0%

10%

20%

30%

40%

50%

60%

70%

Uns

atisfie

d

Satis

fied

Goo

d

Excelle

nt

Patients Subjective Outcome

Stapled Hemorrhoidopexy

Initially introduced by Longo in 1998 by modifying EEA staplingtechnique used in rectal surgery

Utilizes a 33mm circular stapler passed via the anal canal

Essentially lifts or repositions the anal canal tissue

Procedure generally performed in about 30-45 minutes

Remaining internal hemorrhoid tissues shrinks within 4 to 6weeks

Hemorrhoids have been and will continue to be aprominent healthcare issue for the American population.Stapled hemorrhoidectomy is a new innovation in the

treatment of prolapsing hemorrhoid disease whichprovides patients with a less painful means of relief,allows quicker return to normal function, and provides ahigh degree of post operative satisfaction.Economically, the procedure requires less operative time

and infrequently necessitates hospitalization. Thestapler, however, is costly and is not reusable.The technique is still relatively new, and reliable

randomized, controlled trials to date are small withoutgood long term results for assessing durability.

Conclusion

Pitfalls of study

Retrospective survey of patient population

No comparison group

No good long term follow up to assess durability

Survey addresses only subjective data

Other procedures may have influenced outcomesassessment

Discussion

Review of Literature

European study of 1077 patientsconcluded that patients who had PPH

had less pain, shorter hospital stays,shorter operative time, quicker return tonormal activity and no difference inquality of life scores. They did howeverhave a higher recurrence rate.*

A similar US study of 117 patientsconcluded PPH offers benefits of lesspost operative pain, less analgesicrequirements, and less pain at first bowelmovement, while providing similar controlof symptoms.**

A French study compared stapledhemorrhoidopexy verses Milligan-Morganwith 2 year follow up.

A series of 134 patients in 7 centers wereevaluated preoperatively and 6 weeks, 1year and 2 years post treatment. Theyconcluded PPH caused less pain,achieved comparable outcomes and wasequally effective in relieving symptoms.

**A Prospective, Randomized, Controlled Mult icenter Trial Comparing Stapled Hemorrhoidopexy and Ferguson Hemorrhoidectomy:Perioperative and One-Year Results. A. J. Senagore, et.al. Diseases of the Colon & Rectum Vol.47,No.11

*Stapled Hemorrhoidopexy Compared With Conventional Hemorrhoidectomy: Systematic Review of Randomized, Controlled Trials.Pasha J. Nisar1, et.al. Diseases of the Colon & Rectum Vol.47 No.11

Stapled Hemorrhoidopexy Versus Mill igan-Morgan Hemorrhoidectomy: A Prospective,Randomized, Mult icenter Trial With 2-Year Postoperative Follow Up. Gravi,JeanFranoisMD,et.al.Annalsof Surgery.242(1):29-35,July2005.

Follow upPost op visits (13 patients lost tofollow up)Range: 0-11Average: 1.6 visitsMean time to discharge: 10.8 wksDischarge Mode: 1 visit 3 wkspost op

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