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Excision of residual skin tags during stapled anopexy does not increase postoperative pain
Linköping University, Department of Clinical and Experimental Medicine, Surgery . Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Centre of Surgery and Oncology, Department of Surgery in Östergötland.
Linköping University, Department of Clinical and Experimental Medicine, Surgery . Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Centre of Surgery and Oncology, Department of Surgery in Östergötland.
2007 (English)In: Colorectal Disease, ISSN 1462-8910 (print) 1463-1318 (online), Vol. 9, no 8, 754-757 p.Article in journal (Refereed) Published
Abstract [en]

Objective: We studied whether excision of residual external skin tags causes additional pain in patients undergoing a stapled anopexy for muco-anal prolapse.

Method: Seventeen patients in whom skin tags had been excised were compared with 24 patients having no excision. The patients were selected from a prospective database of haemorrhoid surgery if they had submitted a diary with self-reported postoperative pain scores as well as a self-reported symptom questionnaire preoperatively and postoperatively. The tags were excised with preservation of the subdermal fascia.

Results: There were 41 patients who fulfilled the criteria for inclusion. Seventeen (group 1) had tags excised and 24 (group 2) did not. Fifty-nine per cent in group 1 and 67% in group 2 experienced preoperative prolapse needing manual reposition. The mean height of the staple line was 2 cm above the dentate line in both groups. Daily average postoperative pain recorded as the sum of a self-reported VAS rating over 14 days was 26 points in both groups. The peak pain experienced was 42 and 43 points respectively (not significant). Resolution of postoperative pain over 14 days was identical. The preoperative and postoperative symptom score was comparable in both groups.

Conclusion: Excision of anal skin tags should be carried out at the time of stapled anopexy.

Place, publisher, year, edition, pages
2007. Vol. 9, no 8, 754-757 p.
Keyword [en]
Haemorrhoids, surgery, stapless, postoperative pain, ropivacain
National Category
Medical and Health Sciences
URN: urn:nbn:se:liu:diva-13288DOI: 10.1111/j.1463-1318.2007.01237.xOAI: diva2:18214
Available from: 2008-05-13 Created: 2008-05-13 Last updated: 2009-08-18
In thesis
1. Outcome After Haemorrhoidopexy
Open this publication in new window or tab >>Outcome After Haemorrhoidopexy
2008 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: This dissertation is composed of five individual studies of the stapled haemorrhoidopexy operation. The operation was launched to an international audience in 1998 by the Italian surgeon Antonio Longo. In conventional surgery the prolapsed piles are excised from the anodermal part of the prolapse up through the anal canal into the lower rectal mucosa where the pile is divided with diathermy or suture ligated and excised. It leaves open wounds throughout the anal canal. These wounds can be very painful, especially at defecation, and will take from three to six weeks to heal. In the stapled haemorrhoidopexy operation symptomatic haemorrhoids are seen as a disease of anodermal, haemorrhoidal and rectal mucosal prolapse of varying degree. The main component of the prolapse is the redundancy of rectal mucosa. By pushing back the prolapse into the anal canal followed by excision of the mucosal redundancy above the anal canal with a circular stapler devise a mucosal anastomosis is fashioned. This anastomosis is situated immediately above the haemorrhoids and will attach them to the rectal muscular wall to prevent further prolapse. The operation is associated with substantially less pain and a quicker recovery.

Methods: For the five studies, a total of 334 patients were operated for haemorrhoidal prolapse. The first operations were performed in February 1998. All patients were assessed preoperatively and postoperatively with the same set of protocols as follows. The symptoms of haemorrhoids were scored with a questionnaire to patients to obtain their independent statements of the frequency of each of five cardinal symptoms: pain, bleeding, pruritus, soiling and prolapse in need of manual reduction. A diary was used by patients to report daily pain scores, use of pain medication and speed of recovery within the first 14 postoperative days. The surgeon rated the deranged anal anatomy before and after surgery. We also developed an algorithm based on the patients’ statement of digital reduction of prolapse (grade 3) and the surgeon’s assessment of lesser prolapse at proctoscopy (grade 2). Absence of prolapse was grade 1. The surgeon also provided statements about the conduct of the operation and rated the technical complexity. The information, for all patients, was entered into an electronic data base.

Results: One registry based study and one prospective randomised controlled trial assessed the advantage of performing the operation under perianal local anaesthetic block. The postoperative pain and surgical outcome was independent of the type of anaesthesia. No operation under local block had to be converted to general anaesthesia. Anodermal prolapse is seen in 70 percent of the patients. In a registry-based study we found that excision of the anodermal folds did not increase the postoperative pain provided the excision stopped at the anal verge. In 270 patients with precise preoperative and postoperative classification we found that the symptomatic load was identical for grades 2 and 3. The symptoms were independent of the anodermal prolapse. The symptoms were greatly reduced when the operation turned out grade 1 prolapse. The long-term result was assessed in 153 patients operated 1 year to 6 years previously. The need for early re-intervention was 6.2 percent representing technical error to reduce the prolapse. At the final evaluation 12 patients (8.2 percent) complained of a mucoanal prolapse in need of digital reduction. The mean symptom burden had been reduced from 8.1 to 2.5 points but 17 percent had at least one cardinal symptom with a weekly frequency.

Conclusions: Stapled haemorrhoidopexy should be performed as day surgery under local anaesthesia. Any remaining anodermal prolapse should be excised. The optimal long-term outcome is grade 1A or 1B with low symptom score. There was an 87 percent chance of cure of the prolapse with the first haemorrhoidopexy. About half the failures were insufficient primary surgery and half a relapse of the prolapse.

Place, publisher, year, edition, pages
Linköping University Electronic Press, 2008. 76 p.
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1064
Haemorrhoids, haemorrhoidopexy, surgery, local anaesthesia, classification, prolapse
National Category
urn:nbn:se:liu:diva-11797 (URN)978-91-7393-903-4 (ISBN)
Public defence
2008-05-30, Berzeliussalen, Campus US, Linköpings universitet, Linköping, 13:00 (English)

The original title of article IV was "Prolapse grade and symptoms of haemorrhoids are poorly correlated: result of a classification algorithm in 270 patients. The new title after publishing the article is "Grade of prolapse and symptoms of haemorrhoids are poorly correlated: result of a classification algorithm in 270 patients".

Available from: 2008-05-13 Created: 2008-05-13 Last updated: 2015-11-19

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Gerjy, RogerNyström, Per-Olof
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Surgery Faculty of Health SciencesDepartment of Surgery in Östergötland
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