Prospective study of factors affecting postoperative pain and symptom persistence after stapled rectal mucosectomy for hemorrhoids: a need for preservation of squamous epithelium.

PURPOSE The purpose of the study was to determine the variables associated with postoperative pain and the clinical response of patients with uncomplicated hemorrhoidal disease treated with stapled rectal mucosectomy in the medium term. METHODS Patients with Grade II to IV, uncomplicated hemorrhoidal disease who underwent stapled rectal mucosectomy were prospectively included. The basal characteristics of the population were evaluated and level of stapling and placement of hemostatic suture determined. Histologically, the type of resected epithelium and presence of muscle fibers was evaluated. Postoperative pain was evaluated by means of a visual analog scale. Complications and clinical response were evaluated. RESULTS One hundred patients with a mean age of 43.9 years were included. Only columnar epithelium was resected in 48, transitional epithelium in 47, and squamous epithelium in 5 patients. Smooth muscle fragments were found in 55 patients, and, in 12 of these, fibers from the external muscular layer of rectum were also seen. Follow-up was 12.6 +/- 3.4 (range, 7-24) months. A total of 79 patients were completely asymptomatic at the end of follow-up. Resected squamous epithelium was associated with a higher postoperative pain level in the multivariate analysis (coefficient beta = 1.16 (95 percent confidence interval, 0.08-2.24); P = 0.035). CONCLUSIONS Rectal mucosectomy with stapler is an effective method for the treatment of uncomplicated prolapsing hemorrhoidal disease. Intensity of postoperative pain was associated with the type of resected epithelium. This suggests that low transection of hemorrhoids must be avoided.

Stapled rectal mucosectomy vs. closed hemorrhoidectomy: a randomized, clinical trial.

INTRODUCTION: We compared the safety and clinical outcome between stapled rectal mucosectomy and closed hemorrhoidectomy for the surgical treatment of noncomplicated hemorrhoidal disease. METHODS: Eighty-four patients with Grade III and IV hemorrhoidal disease were randomly assigned to two groups: 1) stapled rectal mucosectomy group (n = 42) and 2) closed hemorrhoidectomy group (n = 42). Postoperative pain, analgesic use, symptoms, disability, early and late complications, and patient satisfaction were evaluated, among others. Follow-up was six months. RESULTS: Eighty-four patients, averaging 45 +/- 9 years of age, underwent surgery. Two were lost to follow-up. Length of surgery and disability, postoperative pain, and use of analgesics were significantly less for patients in the stapled rectal mucosectomy group. In the closed hemorrhoidectomy group early complications were more frequent but not statistically significant, and there were no statistically significant differences regarding the frequency of late complications. No serious complications were reported in either group. Closed hemorrhoidectomy proved to be superior for bleeding control (95.1 percent closed hemorrhoidectomy 80.5 percent stapled rectal mucosectomy; P= 0.04). Patient satisfaction was similar in the two groups, but stapled rectal mucosectomy patients were more willing to undergo the same procedure (P = 0.02). CONCLUSION: Both stapled rectal mucosectomy and closed hemorrhoidectomy are safe procedures. Closed hemorrhoidectomy was superior for bleeding control in Grade III and IV hemorrhoidal disease, but more painful and disabling than stapled rectal mucosectomy.