Prospective Randomized Study on Stapled Anopexy Height and Its Influence on Recurrence for Hemorrhoidal Disease Treatment.

OBJECTIVES: To know the influence of the stapled line height (SLH) in the recurrence rate and the postoperative disturbances in stapled anopexy (SA) for the treatment of hemorrhoids. DESIGN: Simple randomized double-blind controlled clinical trial. Randomization with closed-envelope technique in two groups with two different SLH. SETTING: Colorectal Surgery Unit. Department of General Surgery. Hospital de Mataró (Barcelona, Spain). PARTICIPANTS: 119 patients with the diagnosis of symptomatic third- and fourth-grade hemorrhoids were included. INTERVENTION: SA was performed with two different SLH: group A, 4.5 cm (58 patients) and group B, 6 cm (61 patients) from the external anal verge. Postoperative disturbances were evaluated by a colorectal surgeon who was blind for the randomization and pain was measured (visual analogic scale) one week and 3 months after surgery. Mean operative time, number of hemostatic stitches performed and resected mucosal area were considered as well. Mean follow-up was 11.05 ± 1.6 years. RESULTS: Differences between the operative time and resected mucosa-submucosa area were not found. The patients of group A needed a significantly higher number of stitches for intraoperative bleeding control along the stapled line. We did not found differences between both groups in terms of postoperative pain neither anorectal disturbances. At the follow-up, persistence of symptomatology was 10.41% in group A and 10.71% in group B, without statistically significance. Neither mortality nor undesirable effects occurred in the series. CONCLUSIONS: SLH do not influence the recurrence rate neither the postoperative evolution in SA. TRIAL REGISTRATION: Clinical Trials NCT03383926.

Anopexia mucosa grapada: experiencia y consideraciones sobre la técnica / Circular mucosal anopexy: Experience and technical considerations

INTRODUCCIÓN: La anopexia mucosa circular (AMC) condiciona un postoperatorio menos molesto que las técnicas resectivas, pero no está exenta de complicaciones y presenta una mayor recidiva. El objetivo del presente estudio es evaluar la eficacia de la AMC en el tratamiento de las hemorroides y del prolapso mucoso rectal (PMR). MÉTODOS: Entre 1999 y 2011 fueron intervenidos en nuestro hospital 613 pacientes por hemorroides o PMR: en 327 casos se realizó AMC (PMR en 28 casos, grado II en 46, grado III en 146 y grado IV en 107 casos). La AMC se realizó en régimen de cirugía mayor ambulatoria (CMA) en el 79% de los casos. Consideramos la recidiva y comparamos los grupos de no recidiva y recidiva. Evaluamos el dolor medido por Escala Visual Analógica (EVA) y las complicaciones postoperatorias. RESULTADOS: En 31 pacientes se registró recidiva de la sintomatología que precisó algún tipo de intervención: PMR en 5 pacientes, grado II en 2, grado III en 17 y grado IV en 7. No existieron diferencias significativas entre los pacientes con reccidiva y los pacientes sin recidiva en cuanto a género, tiempo operatorio ni grado hemorroidal, pero sí respecto a la edad. El 81,3% de los pacientes expresó dolor ≤ 2 en EVA a la semana. Cinco pacientes se reintervinieron por sangrado postoperatorio inmediato. Seis pacientes precisaron ingreso por dolor postoperatorio. CONCLUSIONES: La recidiva en la AMC es superior a la de las técnicas resectivas. La AMC es una técnica útil para el tratamiento de la enfermedad hemorroidal en régimen de CMA. El grado de dolor y las complicaciones son bajos

INTRODUCTION: Circular mucosal anopexy (CMA) achieves a more comfortable postoperative period than resective techniques. But complications and recurrences are not infrequent. This study aims to evaluate of the efficacy of CMA in the treatment of hemorrhoids and rectal mucosal prolapse (RMP). METHOD: From 1999 to 2011, 613 patients underwent surgery for either hemorrhoids or RMP in our hospital. CMA was performed in 327 patients. Gender distribution was 196 male and 131 female. Hemorrhoidal grades were distributed as follows: 28 patients had RMP, 46 2nd grade, 146 3rd grade and 107 4th grade. Major ambulatory surgery (MAS) was performed in 79.9%. Recurrence of hemorrhoids was studied and groups of recurrence and no-recurrence were compared. Postoperative pain was evaluated by Visual Analogical Scale (VAS) as well as early complications. RESULTS: A total of 31 patients needed reoperation (5 RMP, 2 with 2nd grade, 17 with 3rd grade,/with 4th grade). No statistically significant differences were found between the non-recurrent group and the recurrent group with regards to gender, surgical time or hemorrhoidal grade, but there were differences related to age. In the VAS, 81.3% of patients expressed a postoperative pain ≤ 2 at the first week. Five patients needed reoperation for early postoperative bleeding. Six patients needed admission for postoperative pain. CONCLUSIONS: Recurrence rate is higher in CMA than in resective techniques. CMA is a useful technique for the treatment of hemorrhoids in MAS. Pain and the rate of complications are both low

Circular mucosal anopexy: Experience and technical considerations. / Anopexia mucosa grapada: experiencia y consideraciones sobre la técnica.

INTRODUCTION: Circular mucosal anopexy (CMA) achieves a more comfortable postoperative period than resective techniques. But complications and recurrences are not infrequent. This study aims to evaluate of the efficacy of CMA in the treatment of hemorrhoids and rectal mucosal prolapse (RMP). METHOD: From 1999 to 2011, 613 patients underwent surgery for either hemorrhoids or RMP in our hospital. CMA was performed in 327 patients. Gender distribution was 196 male and 131 female. Hemorrhoidal grades were distributed as follows: 28 patients had RMP, 46 2nd grade, 146 3rd grade and 107 4th grade. Major ambulatory surgery (MAS) was performed in 79.9%. Recurrence of hemorrhoids was studied and groups of recurrence and no-recurrence were compared. Postoperative pain was evaluated by Visual Analogical Scale (VAS) as well as early complications. RESULTS: A total of 31 patients needed reoperation (5 RMP, 2 with 2nd grade, 17 with 3rd grade,/with 4th grade). No statistically significant differences were found between the non-recurrent group and the recurrent group with regards to gender, surgical time or hemorrhoidal grade, but there were differences related to age. In the VAS, 81.3% of patients expressed a postoperative pain ≤ 2 at the first week. Five patients needed reoperation for early postoperative bleeding. Six patients needed admission for postoperative pain. CONCLUSIONS: Recurrence rate is higher in CMA than in resective techniques. CMA is a useful technique for the treatment of hemorrhoids in MAS. Pain and the rate of complications are both low.

Anopexia mucosa circular en el tratamiento de las hemorroides y del prolapso mucoso rectal: complicaciones y resultados / Circular mucosal anopexy in the treatment of hemorrhoids and rectal mucosa prolapse: complications and results

Introducción. La anopexia mucosa circular (AMC) es una técnica de reciente descripción que intenta reducir el dolor postoperatorio en caso de intervención quirúrgica por hemorroides y/o prolapso mucoso rectal. El objetivo del presente estudio descriptivo es evaluar los resultados de nuestro grupo con la utilización de la AMC. Pacientes y método. Hemos intervenido a 96 pacientes con AMC (61 varones y 35 mujeres) en 4 años: 22 casos de prolapso mucoso rectal y 74 de hemorroides (19 de grado II, 27 de grado III y 28 de grado IV). La AMC se realizó con el equipo PPH01TM (Ethicon Endosurgery) y en 63 casos a través de la unidad de cirugía mayor ambulatoria. Se valoraron prospectivamente el dolor postoperatorio, las complicaciones inmediatas y la eficacia de la técnica (seguimiento medio, 23,1 meses; rango, 6-49 meses). Resultados. El 82 por ciento de los pacientes manifestó dolor por debajo de 2 en la escala analógica visual de dolor (0-10) a las 24 h. La urgencia defecatoria y el tenesmo rectal, ambos leves, han sido constantes en la primera semana y han desaparecido con posterioridad. Se produjeron 8 casos (8,3 por ciento) de incontinencia leve autolimitada en los primeros 3 meses, y 4 pacientes presentaron complicaciones hemorrágicas graves, de los que 3 precisaron reintervención y hemostasia de la línea de grapado y 1 presentó un hematoma perirrectal que se trató de manera conservadora. En el seguimiento, 74 pacientes se hallan asintomáticos (77,1 por ciento), en 17 (17,7 por ciento) ha disminuido la sintomatología de forma evidente y 5 pacientes han requerido reintervención por fracaso de la técnica. Conclusiones. Hemos conseguido una eficacia notable en el tratamiento de las hemorroides y del prolapso mucoso rectal mediante la AMC, con un índice de complicaciones aceptable. El éxito de la AMC se basa en su implantación progresiva y la aplicación de una técnica quirúrgica cuidadosa. Su eficacia a largo plazo está pendiente de seguimientos más prolongados (AU)