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Outcome After Haemorrhoidopexy
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.
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.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1064
Keyword [en]
Haemorrhoids, haemorrhoidopexy, surgery, local anaesthesia, classification, prolapse
National Category
Surgery
Identifiers
URN: urn:nbn:se:liu:diva-11797ISBN: 978-91-7393-903-4 (print)OAI: oai:DiVA.org:liu-11797DiVA: diva2:18217
Public defence
2008-05-30, Berzeliussalen, Campus US, Linköpings universitet, Linköping, 13:00 (English)
Opponent
Supervisors
Note

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
List of papers
1. Perianal local block for stapled anopexy
Open this publication in new window or tab >>Perianal local block for stapled anopexy
2006 (English)In: Diseases of the colon and rectum, ISSN 0012-3706, Vol. 49, no 12, 1914-1921 p.Article in journal (Refereed) Published
Abstract [en]

Purpose This study was designed to demonstrate the usefulness of a method of regional anesthesia for circular stapler anopexy for prolapsing hemorrhoids.

Methods Thirty-three patients consented to stapled anopexy under perianal local anesthesia. Eighteen patients with stapled anopexy under general anesthesia were controls. The perianal block was applied with 40 ml of ropivacaine, 4.75 mg/ml, injected immediately peripheral to the external sphincter. A submucosal block with 15 ml of ropivacaine, 2 mg/ml, was added after applying the pursestring suture. Postoperative pain was rated by the patient for 14 days by using a ten-point visual analogue scale. Patients also submitted a preoperative and postoperative (3–6 months) symptom questionnaire to rate anal symptoms.

Results No operation was converted to general anesthesia. Operation time was similar in both groups. All patients in the local anesthesia group were pain free at discharge. The sums of pain scores during 14 days for daily average pain and peak pain were similar in both groups (average pain 23 (local anesthesia) vs. 35 (general anesthesia); peak pain 39 (local anesthesia) vs. 50 (general anesthesia); P > 0.05). The preoperative symptom scores were 7.8 (local anesthesia) vs. 8.9 (general anesthesia) points, and the follow-up scores were 2.2 (local anesthesia) and 2.7 (general anesthesia), a significant improvement (P = 0.001) in both groups but not different between groups.

Conclusions A perianal local block is easy to apply and has a high degree of acceptance among patients. The operation time, postoperative pain, and success rates of the operation equaled those of stapled anopexy performed under general anesthesia. The advantages are quicker turnover between cases and simpler management of pain-free postoperative patients in day surgery.

Keyword
Hemorrhoids, Surgery, Perianal, Anesthesia, Ropivacaine, Anopexy, Stapler
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13286 (URN)10.1007/s10350-006-0750-8 (DOI)
Available from: 2008-05-13 Created: 2008-05-13 Last updated: 2009-05-15
2. Randomized clinical trial of stapled haemorrhoidopexy performed under local perianal block versus general anaesthesia
Open this publication in new window or tab >>Randomized clinical trial of stapled haemorrhoidopexy performed under local perianal block versus general anaesthesia
2008 (English)In: British Journal of Surgery, ISSN 0007-1323, Vol. 95, no 11, 1344-1351 p.Article in journal (Refereed) Published
Abstract [en]

Background: The aim was to assess the feasibility of performing stapled haemorrhoidopexy under local anaesthesia.

Methods: Fifty-eight patients with haemorrhoid prolapse were randomized to receive local or general anaesthesia. The perianal block was applied immediately peripheral to the external sphincter. Submucosal block was added after applying the purse-string suture. Patients reported average and peak pain daily for 14 days using a visual analogue scale (VAS). They also completed anal symptom questionnaires before the operation and at follow-up. The surgeon assessed the restoration of the anal anatomy 3-6 months after surgery.

Results: The anal block was sufficient in all patients. The mean accumulated VAS score for average pain was 23·1 in the general anaesthesia group and 29·4 in the local anaesthesia group (P = 0·376); mean peak pain scores were 42·1 and 47·9 respectively (P = 0·537). Mean change in symptom load was also similar between the groups, with score differences of 7·0 in the general anaesthesia group and 6·1 in the local anaesthesia group. No patient had a recurrence of prolapse.

Conclusion: Perianal local block is easy to apply with a high degree of acceptability among patients. Postoperative pain, restoration of anatomy and symptom resolution were similar to that of stapled haemorrhoidopexy performed under general anaesthesia.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13287 (URN)10.1002/bjs.6379 (DOI)
Available from: 2008-05-13 Created: 2008-05-13 Last updated: 2009-04-28
3. Excision of residual skin tags during stapled anopexy does not increase postoperative pain
Open this publication in new window or tab >>Excision of residual skin tags during stapled anopexy does not increase postoperative pain
2007 (English)In: Colorectal Disease, ISSN 1462-8910, 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.

Keyword
Haemorrhoids, surgery, stapless, postoperative pain, ropivacain
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13288 (URN)10.1111/j.1463-1318.2007.01237.x (DOI)
Available from: 2008-05-13 Created: 2008-05-13 Last updated: 2009-08-18
4. Prolapse grade and symptoms of haemorrhoids are poorly correlated: result of a classification algorithm in 270 patients
Open this publication in new window or tab >>Prolapse grade and symptoms of haemorrhoids are poorly correlated: result of a classification algorithm in 270 patients
2008 (English)In: Colorectal disease, ISSN 1462-8910, Vol. 10, no 7, 694-700 p.Article in journal (Refereed) Published
Abstract [en]

Purpose: Haemorrhoid prolapse is an indication for surgery. A correlation between worsening anatomy and increasing symptoms is commonly assumed. We developed a classification algorithm of prolapse and external component, and evaluated its correlation to symptoms before and after surgery.

Method: A study population comprising 180 patients operated for haemorrhoids in a multicentre randomized trial plus a validation set comprising 90 patients operated by us. The classification used three items: (i) patient self-report of prolapse requiring manual reposition; (ii) surgeon assessment of prolapse when patient negated manual reposition; (iii) surgeon assessment of external component. Patient self-reported were rated by frequency (never, 0 points; monthly, 1 point; weekly, 2 points and daily, 3 points). The algorithm yielded three grades: 1, no prolapse; 2, spontaneously reducing prolapse and 3, prolapse needing manual repositioning. The degree of external component was affixed as A, none; B, one or few tags and C, circumferential.

Results: Anatomical grades did not differ between the two sets of patients before or after surgery. Preoperatively, 69% had grade 3 prolapse. Postoperatively, 89% were classified as grades 1A or B. The symptom load was similar for grades 2 and 3; mean 6.5 points preoperatively and 1.8 points postoperatively.

Conclusion: This anatomical classification, based on strict criteria, reliably staged the haemorrhoid prolapse. There was no unique preoperative symptom profile associated with any degree of prolapse with or without an external component. Restored anal anatomy relieved symptoms. The classification also defined recurrence of haemorrhoids.

Keyword
Haemorrhoids, Haemorrhoidopexy, grade, classification, symptoms, prolapse
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13289 (URN)10.1111/j.1463-1318.2008.01498.x (DOI)
Available from: 2008-05-13 Created: 2008-05-13 Last updated: 2009-08-18
5. Longterm result of stapled haemorrhoidopexy: A prospective single centre study of 153 patients with 1-6 years followup
Open this publication in new window or tab >>Longterm result of stapled haemorrhoidopexy: A prospective single centre study of 153 patients with 1-6 years followup
Manuscript (Other academic)
Identifiers
urn:nbn:se:liu:diva-13290 (URN)
Available from: 2008-05-13 Created: 2008-05-13 Last updated: 2010-01-13

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