ACTA FAC. MED. NAISS. 2003; 20 (3): 163-168

Original article

SURGICAL TREATMENT OF INTERNAL HEMORRHOIDES WITH STAPLER HEMORRHOIDECTOMY
 

Goran Stanojević, Dragoslav Miljković, Milan Jovanović, Miroslav Stojanović, Aleksandar Nagorni Surgical Clinic, Clinical Center Niš, Clinic for Gastroenterology and Hepatology, Clinical Center Niš
 

INTRODUCTION

Hemorrhoidal disease is a very common condition in modern surgical practice. It is usually defined as a group of symptoms caused by the complications involving the hemorrhoidal tissue.
Hemorrhoidal tissue or hemorrhoids represent anatomic and vascular formations normally present in everyone after birth. Transition from this anatomical condition into the hemorrhoidal disease occurs through non-specific functional symptoms, with rectorrhagia as the most prominent.
It is thought that around 70% of adult population above 30 is affected with this disease. It is more common in males, with the maximal incidence between 45 and 65 years of age (1).
Internal hemorrhoids do not imply a diseased status. They are considered a disease only after the complications: bleeding, protrusion, thrombosis, inflammation.
Up-to-date hemorrhoidal treatment implies conservative and surgical approaches. Conservative approach is indicated mostly for hemorrhoides stage I and II.
Surgical treatment is indicated for hemorrhoids stage IV. There is a dilemma regarding the treatment of stage III: some authors recommend conservative treatment while others suggest surgical treatment (2). Due to that fact, stage III hemorrhoidal disease is further subdivided into two stages depending on the position of dental line: IIIa stage connotes normal dental line position within the anal channel; IIIb connotes partial or complete dental line dislocation towards the anal channel outlet. Stage IIIa requires conservative while stage IIIb requires surgical treatment.
Within the group of traditional surgical interventions there are many approches used in the past or still in use today (Langenbeck, Ferguson, Whitehead, Parks methods), but the most common approach is Miligan-Morgan method. The basic characteristic of these procedures are the ligation of terminal branches of hemorrhoidal artery and hemorrhoidectomy (3).
However, numerous postoperative complications - bleeding, pain, unnecessary hospitalization - urged the search for other, less invasive procedures. During the 1980s in Italy, hemorrhoidectomy with automatic suturation device was mentioned for the first time. In 1993 Antonio Longo reaffirmates the method with some alterations (it was later named after him) (4). A basic feature of stapler hemorrhoidectomy is minimally invasive intervention, with transanal simultaneous ligation of all terminal branches of a. hemorrhoidalis involved in internal hemorrhoides vascularization and with the reduction of rectal mucosal prolapse. Due to the current significance of stapler application in internal hemorrhoides treatment we decided to analyze the complications after hemorrhoidectomy with automatic suture device based on our clinical experience.
 

MATERIAL AND METHODS

From September 2001 to November 2003 at the Surgical Clinic in Nis, 20 patients were operated, averagely aged 39.6 years (ranging from 28 to 53), out of whom 12 were men (60%) and 8 were women (40%). In all of them internal grade III and IV hemorrhoides were documented, with a degree of mucosal prolapse.
All surgical interventions were performed with preoperative colonic preparation (enema on the day preceding the operation; prophylactic antibiotics - 500 mg of metronidasole and 1.5 g cefuroxim - one hour before the operation).
Patients were placed into the lytotomic position in general anesthesia. Detailed exploration of the anorectal region is performed with Schulze-Bergmann anal retractor - Martin®. After dental line identification, mild eversion of the anal channel is performed with atraumatic clamps.
At 4-5 cm from the dental line cranially, beginning from the anterior rectal wall clockwise a tobacco pouch suture was made, pertaning to involve the mucose and submucosal layer. For the pouch suture monofilament suture 2-0 is used.
After that a maximally open Ethicon Endo Surgery 33 mm hemorrhoidal stapler is inserted in the anal channel direction to the point where its "head" reaches the position above the tobacco pouch suture. The siture is then tightened around the axis of the automatic suture device. In that position it is necessary to check the position of the tightened pouch suture, ie. whether it is positioned symetrically at least 2 cm from the dental line. After the stapler is triggered, it is gently pulled out of the anal canal in a maximally open position. The tissue around the stapler axis is checked (whether there is the total circumference) and the sample is sent for histopathology. After stapler withdrawal hemostasis is monitored.
Operations usually lasted 28 minutes (range, 15-50 minutes).
Patients were dismissed from the hospital on the average 15 hours after operation (range, 6-72 hours).
RESULTS
In all cases one tobacco pouch suture was utilized. On checking the suture line after stapler withdrawal, it was established that in 16 cases (80%) the line was present along the whole rectal circumference, while in 4 cases there were suture line discontinuities.
The following complications were monitored throughout the postoperative course:
- pain,
- bleeding,
- urinary retention,
- edema of the anal and perianal region,
- submucous hematoma.
Pain intensity was measured with visual analogue scale of pain (VAS) in the period of 5 days after the operation, using the range of values from 0=no pain, to 10= the most severe pain.
Patients were asked to write down VAS values for the previous 24 hours as well as for defecation. In cases of pain, the use of 500 mg metamisole (with written down number of tablets taken for the 5 days' postoperative period) was recommended.
In 15 patients (75%) pain value was registered in the range 2.5-3.5, while in 5 examinees pain intensity was below 2.5; however, 15 examinees (75%) took analgetics in the period of 5 postoperative days (average dose 1 g; range: 500 mg-2 g) and 5 patients (25%) did not use analgetics.

Table 1. Average pain scale values by days
 

In 10 patients (50%), as a preventive hemostatic tool, homologous fibrin glue was used (Blood Transfusion Centre Niš) as a topical suture line application, while in 2 cases (10%) SPONGOSTAN® (8 cm x 3 cmŘ) was applied in the anal channel. In the remaining 8 patients (40%) we did not use any additional hemostatic tool.
In one case (5%) urinary retention occurred, so bladder catheterization was performed (Foley catheter). Edema of the anal and perianal region was present in 2 patients (10%), with spontaneous sanation in both instances. In 2 patients (10%) submucous hematoma was observed which spontaneously resolved.
 

 Table 2. Comparison of the pre- and postoperative symptoms

DISCUSSION

Hemorrhoidal disease is one of the most frequent benign diseases in modern surgical practice. In most cases conservative therapy is the treatment of choice. However, in cases of grade III and IV disease, the only effective therapy is surgery. Modern surgery is characterized with a better knowledge of anatomical, pathophysiological and microbiologic features of the anorectum, and the nature of the disease on one hand, and with well trained and experienced surgeons on the other.
To this, one should add the latest developments in preoperative preparation, reanimation and antibiotics application. There can be no doubt that the up-to-date surgery of hemorrhoidal disease engaged a significant number of clinical disciplines, intensified investigational activities and helped scientific results to be successfully integrated into everyday practice.
The history of hemorrhoidal disease treatment has its beginnings in the Hippocrates times (who termed anal channel bleeding as hemorrhoids). In the ancient Egypt, India and Mesopotamia there were even specialists for that disease.
Modern hemorrhoidal surgery is characterized by numerous intervention methods such as Milligan-Morgan, Parks, Ferguson, which, though originating more than 75 years ago, still represent the golden standard (5). During the past several decades investigational work was intensified in the direction of possible out-patient hemorrhoid treatment: sclerotherapy, ligation, cryotherapy and infrared coagulation. Minimally invasive procedures develop intensely during the last 10 years; those are Doppler-guided ligation of the hemorrhoidal artery branches, hemorrhoidectomy with ultrasound dissector and stapler-hemorrhoidectomy. According to the literature data, stapler-hemorrhoidectomy is less risky procedure as it enables conservation of a larger mucosal portion and it lasts significantly less compared to conventional surgical approaches (6-11).
The analysis of the causes of postoperative complications in our clinical series demonstrates that pain is the most common cause of morbidity in 75% of the cases, but that it is easily alleviated with appropriate analgetics. On the other hand, other complications are less frequent: urinary retention in 5%, edema of the anal and perianal region in 10%, and submucous hematoma in 10% of the patients.
The comparison of the disease symptoms before, and one month after the intervention indicated that bleeding, pain and hemorrhoidal prolapse completely subside in the postoperative period, which is of an enormous significance from the treatment success point of view.
Longo published his study results in 1998; the study enrolled 144 patients and stapler hemorrhoidectomy pain was present in 79.2% of the cases, urinary retention in 9.7%, edema of the anal and perianal region in 3.4% and submucous hematoma in 3.4% of the cases. Comparing the symptoms before and one month after the operation, the same author noted that the bleeding present preoperatively in 70.1%, persisted one month postoperatively in 2.97%, partially improved in 2.79% and completely resolved in 76.23%. Pain was preoperatively present in 12.5%; postoperatively, it persisted in 5.5%, improved in 50% and resolved in 44.4%. Secernation from the anal channel was observed in 13.1% of the cases preoperatively; postoperatively, it persisted in 36.8%. It was improved in 31.6% and resolved in 31.6% (4).
Milito et al. published their results demonstrating that a very severe pain after stapler hemorrhoidectomy occurs in 10.5%, urinary retention in 15.8% and submucous hematoma in 5.2% of the patients (2).
Our own analysis and the results of the above mentioned authors suggest that pain is the most common cause of morbidity but that it does not last long and is relatively mild and easily controlled with analgetics. Other complications are relatively rare and do not require special treatment.
Analysis of the comparation of symptoms in pre- and postoperative periods demonstrates that bleeding and pain almost completely resolve after surgery, while anal channel secernation generally remains.
Histomorphologic analysis of the excised tissue samples demonstrates smooth muscle tissue of the internal sphincter in only 10% of the cases.
Ortiz et al. reported the results of a randomized study in which in 27 patients treated with stapler hemorrhoidectomy histopathology demonstrated in 26% smooth muscle tissue of the internal sphincter was without any significant continence disorder (7).
Histomorphologic analysis of the tissue samples after stapler hemorrhoidectomy shows that the percentage of smooth muscle within the sample is acceptable and that it does not affect continence (concerning bowel gas as well as stool).
 

CONCLUSION

Based on the initial experiences with stapler hemorrhoidectomy we may conclude that:
- stapler hemorrhoidectomy represents a safe and simple procedure,
- stapler hemorrhoidectomy can eliminate hemorrhoidal bleeding,
- stapler hemorrhoidectomy successfully eliminates pain in hemorrhoidal disease,
- stapler hemorrhoidectomy successfully eliminates hemorrhoidal prolapse in hemorrhoidal disease,
- stapler hemorrhoidectomy is a minimally invasive surgical procedure.
 

REFERENCES

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