Keywords
anus - hemorrhoids - stapled hemorrhoidopexy
Hemorrhoids are a common surgical condition, accounting for ∼75% of the Indian population,[1] and they present with symptoms of bleeding, prolapse, itching, pain, and mucous
discharge. For early grades of hemorrhoids, conservative treatment alone or in association
with rubber band ligation showed good treatment outcomes. Additionally, other treatment
options for hemorrhoids, such as infrared coagulation, sclerotherapy, laser therapy,
and cryosurgery, have been used occasionally. However, for higher grade hemorrhoids,
surgery remains the first choice of treatment.
In 1888, the founder of St. Mark's Hospital, Fredrich Solomon, proposed a combination
of excision and ligation of hemorrhoids. Following this, this technique has seen several
modifications with traditional surgery, such as the Fergusson method, the Milligan–Morgan
technique, and diathermy hemorrhoidectomy in an attempt to reduce postoperative pain
with limited degree of success. In 1998, Longo described procedure for prolapse and
hemorrhoids (PPH), a technique for stapled hemorrhoidectomy, which is performed using
a specially designed stapler.[2] The rationale for this procedure is stapled resection of complete circular strip
of the mucosa above the dentate line, lifting hemorrhoidal cushions (anopexy), which
restores the anatomical and physiological anatomy of the hemorrhoidal plexus.[3] PPH was received with enthusiasm, as it could be executed with speed and result
in less postoperative pain and good postoperative outcomes. This technique has become
an alternative to hemorrhoidectomy, which can be reproduced without any subjective
variability.[4]
[5]
However, many studies on postoperative outcomes and complications of stapled hemorrhoidectomy
have been published.[6] Despite constant modifications and refinement of the stapler gun, this technique
has fallen in repute because of the errors by the man behind the machine or occasionally
the machine itself, resulting in both early and late complications. Additionally,
some rare and life-threatening complications of this procedure have been reported.
Stapled hemorrhoidopexy has been described to exclude the sphincter muscle during
purse-string application. The literature suggests that smooth muscle fibers should
be absent in ideal specimens.[7] Much emphasis on the technique of the procedure has been explained by many authors,
especially in taking the purse-string stitch relative to the dentate line and the
depth of the bites, which determines the outcome of this procedure.
Hence, this study was conducted to determine the association between postoperative
complications and the presence of muscle fibers on specimens as an indirect indicator
of doughnut depth.
Materials and Methods
This was a prospective observational study conducted between October 2016 and March
2018 at territory care hospital, Bengaluru. After obtaining the ethical clearance
certificate from the Institutional Ethical Review Board, convenient sampling method
was used for sample size estimation. Patients with symptoms of hemorrhoids were evaluated
in the outpatient department. History taking, physical examination, and proctoscopy
were performed in all patients. The degree of hemorrhoidal disease was evaluated using
the following grading system: Grade 1, dilated blood vessels; Grade 2, prolapsed but
spontaneously reducible piles; Grade 3, piles that required manual reduction; and
Grade 4, permanently prolapsed hemorrhoids.[8] Colonoscopy was recommended and performed in selected cases before surgery. Patients
older than 18 years with Grade 2 hemorrhoids not responding to conservative and day
care procedures and Grades 3 and 4 hemorrhoids were included in the study. However,
Grade 4 hemorrhoids patients were offered other modalities of treatment for their
condition and explained the outcome of each procedure, and it was their choice to
undergo stapler hemorrhoidopexy. Patients with acute prolapsed hemorrhoids, thrombosed
piles, bulky hemorrhoids, fistula-in-ano, fissure-in-ano, recurrent disease, lax sphincter
tone, prior anorectal surgery, local radiation, and malignancy were excluded from
the study. The aforementioned conditions could cause fibrosis in the submucosal layer
resulting in inadvertent sequestration of deeper tissue into the doughnut, which could
alter postoperative outcomes. Approximately 236 patients who met the aforementioned
criteria were offered a choice between conventional hemorrhoidectomy and stapled hemorrhoidopexy
following education on the degree and duration of postoperative pain with each method
and the expenditure involved. Of the 236 patients, 155 chose to undergo stapled hemorrhoidopexy,
and the remaining patients chose to undergo conventional hemorrhoidectomy. Surgery
was performed as an inpatient procedure with enema administered 10 hours before surgery.
A single dose of antibiotic was administered at the beginning of surgery in all patients.
Hemorrhoidopexy was performed in the lithotomy position under spinal anesthesia using
a PPH-03 circular stapler (Ethicon, Inc., NJ). The purse-string suture technique was
performed using half-circle round body 2–0 Prolene on the area 2 cm above the hemorrhoidal
pedicle and at least 4 cm cranial to the dentate line. The doughnut specimen was examined
for completeness and submitted for histopathological examination with due special
consent. The pathologist was requested to report the depth of the doughnut, especially
for the presence or absence of muscle fibers in the given specimen. The patients were
discharged if the following criteria were met: postoperative defecation without a
relevant amount of blood in the stool and good pain control with minimum use of pain
killers. Stool softeners were recommended in all patients after surgery. The patients
were classified into two groups based on the presence or absence of muscle fibers
on histopathological examination of doughnut specimens. Group A consisted of patients
with muscle fiber, whereas Group B comprised patients without muscle of fiber in the
doughnut specimens, and these groups were observed for early and late complications.
Early complications were defined as complications occurring within 7 days after the
operation, whereas late complications were defined as those occurring after 7 days.
Patients were followed up on postoperative days 7 and 14 and at the end of months
1, 6, and 12.
Statistical software R 4.0.3 was used for analysis. To see the association between
two categorical variables, chi-square test was performed. Continues variables were
represented as mean and standard deviation. Categorical variables were represented
as frequency and percentage.
Results
In this study, 155 patients who met the inclusion criteria were included. The mean
age of the patients was 43.6 years. Among them, 57 were females, and 98 were males.
Moreover, 54 patients (34.83%) presented with Grade 2 hemorrhoids, 91 patients (58.70%)
presented with Grade 3 hemorrhoids, and the remaining 10 patients (6.45%) presented
with Grade 4 hemorrhoids. Of the 155 patients, 40 presented with diabetes, 29 presented
with hypertension, and 7 presented with ischemic heart disease as comorbidities.
The main early postoperative complication ([Table 1]) was immediate postoperative pain where 83.22% exhibited tolerable pain with visual
analog scale (VAS) scores of less than 4, 7% patients exhibited VAS scores of 4 to
6, and 9.67% exhibited VAS scores of ≥7. A significant reduction in pain scores was
observed at the end of day 3 with 6.45% of the patients exhibiting VAS scores of 4
to 6 and at the end of day 7 with 3.22% of the patients exhibiting VAS scores of 4
to 6, though proctoscopic examination was unremarkable. Acute urinary retention was
noted in 17 of the 155 patients (10.96%), which required temporary indwelling catheterization;
no patient exhibited urosepsis or chronic urinary retention with significant morbidity.
Other early complications included postoperative bleeding, which was observed in eight
patients (5.16%) of whom three required packing using absorbable hemostatic gelatin
sponges. No patient required blood transfusion or resurgery as all patients recovered
spontaneously. Eight patients (5.16%) exhibited fecal urgency, which resolved at the
end of day 7 as postoperative pain gradually decreased.
Table 1
Early postoperative complications
|
Male (n = 98)
|
Female (n = 57)
|
Total (n = 155)
|
Percentage
|
|
Day 1
|
Day 3
|
D
|
Day 1
|
Day 3
|
Day 7
|
Day 1
|
Day 3
|
Day 7
|
|
Pain VAS <4
|
80
|
91
|
94
|
49
|
54
|
56
|
129
|
145
|
150
|
|
|
Pain VAS 4–6
|
8
|
7
|
4
|
3
|
3
|
1
|
11
|
10
|
5
|
|
|
Pain VAS ≥ 7
|
10
|
|
|
5
|
|
|
15
|
|
|
|
|
Urinary retention
|
|
Present
|
13
|
4
|
17
|
10.96%
|
|
Absent
|
85
|
53
|
138
|
|
|
Bleeding
|
|
Present
|
5
|
3
|
8
|
5.16%
|
|
Absent
|
93
|
54
|
147
|
|
|
Fecal urgency
|
|
Present
|
6
|
2
|
8
|
5.16%
|
|
Absent
|
92
|
55
|
147
|
|
Abbreviation: VAS, visual analog scale.
Sixteen patients (10.32%) presented with proctalgia, characterized by continuous pain
localized at the anus with aggravation during defecation, which is responsive to oral
analgesics. On subjecting these patients to proctoscopy, no clinical evidence of submucous
hematoma, abscess, and granuloma was noticed. This intensity of pain at times had
compromised normal lifestyle and reintegration of work. These patients required long-term
analgesic medications with stool softeners and high-fiber diet, and the symptoms subsided
3 to 4 months after surgery further avoiding for any clinical–radiological investigations.
Moreover, 16 patients (10.32%) exhibited intermittent late postoperative bleeding,
and in 5 patients (3.22%), hemorrhoids recurred 4 to 6 months after surgery, 2 of
whom underwent rubber band ligation, 1 underwent open conventional hemorrhoidectomy,
and 2 refused surgical intervention and opted for conservative management. Note that
four of the five patients with recurrence exhibited Grade 4 hemorrhoids. Other complications
were noted in negligible numbers, including mild incontinence in two patients (1.29%)
and stenosis in two patients (1.29%). Patients with incontinence improved with pelvic
floor exercises, and those with stenosis improved with simple gradual dilatation with
serial dilators ([Table 2]).
Table 2
Late complications
|
Male (n = 98)
|
Female (n = 57)
|
Total (n = 155)
|
Percentage
|
|
Proctalgia
|
|
Present
|
9
|
7
|
16
|
10.32%
|
|
Absent
|
89
|
50
|
139
|
|
|
Bleeding
|
|
Present
|
10
|
6
|
16
|
10.32%
|
|
Absent
|
88
|
51
|
139
|
|
|
Recurrence
|
|
Present
|
3
|
2
|
5
|
03.22%
|
|
Absent
|
95
|
55
|
150
|
|
|
Incontinence
|
|
Present
|
1
|
1
|
2
|
01.29%
|
|
Absent
|
98
|
55
|
153
|
|
|
Stenosis
|
|
Present
|
1
|
1
|
2
|
01.29%
|
|
Absent
|
97
|
56
|
153
|
|
Correlation of Postoperative Complications with the Presence of Muscle Fibers on Histopathology
of Doughnut Specimens Following Stapled Hemorrhoidopexy
On histopathological examination of the doughnut specimens obtained from the 155 patients,
19 patients (12.25%) exhibited muscle fibers indicating that deeper tissue was involved
in the resected specimen ([Figs. 1] and [2]). The postoperative complications in Group A were compared with those in Group B.
Fig. 1 High power magnification of histopathology of a doughnut specimen showing muscle
fibers (arrow head).
Fig. 2 Low power magnification of histopathology of a doughnut specimen showing muscle fibers
(arrow head).
Regarding early complications with the presence of muscle fibers in histopathology
examination ([Table 3]), 16 patients in Group A exhibited pain scores of more than 4 on day 1, whereas
10 patients in Group B exhibited pain scores of more than 4. On day 3, 7 of the 19
patients in Group A and 3 of the 136 patients in Group B exhibited pain scores of
more than 4, whereas on day 7, 4 of the 19 patients in Group A and 1 of the 136 patients
in Group B exhibited pain scores of more than 4. The aforementioned differences were
statistically significant (p ≤ 0.001). Additionally, urinary retention was observed in nine patients in Group
A and eight patients in Group B, and fecal urgency was noted in four patients in Group
A and four patients in Group B, whereas early postoperative bleeding was found in
five patients in Group A and three patients in Group B. The differences in early complications
between the two groups were statistically significant (p ≤ 0.001).
Table 3
Correlation of early complications with the presence of muscle fibers in HPE
|
Presence of muscle fibers in HPE
|
Absence of muscle fibers in HPE
|
p-Value
|
|
Group A (n = 19)
|
Group B (n = 136)
|
|
VAS <4
|
VAS 4–6
|
VAS ≥7
|
VAS <4
|
VAS 4–6
|
VAS ≥7
|
|
Pain day 1
|
3
|
7
|
9
|
126
|
4
|
6
|
<0.001
|
|
Pain day 3
|
12
|
7
|
0
|
133
|
3
|
0
|
<0.001
|
|
Pain day 7
|
15
|
4
|
0
|
135
|
1
|
0
|
0.001
|
|
Urinary retention
|
9 (47%)
|
8 (5.88%)
|
<0.001
|
|
Bleeding
|
5 (26.31%)
|
3 (2.20%)
|
<0.001
|
|
Fecal urgency
|
4 (21.05%)
|
4 (2.94%)
|
0.001
|
Abbreviations: HPE, histopathology examination; VAS, visual analog scale.
Regarding late complications ([Table 4]), seven patients in Group A and nine patients in Group B exhibited proctalgia, and
a similar number of cases exhibited bleeding. The differences in late complications
between the two groups were statistically significant (p < 0.001). No association was found between the two groups in terms of recurrence,
incontinence, and stenosis (p > 0.05).
Table 4
Correlation of late complications with the presence of muscle fibers in HPE
|
Presence of muscle fibers in HPE
|
Absence of muscle fibers in HPE
|
p-Value
|
|
Group A (n = 19)
|
Group B (n = 136)
|
|
Proctalgia
|
7 (36.84%)
|
9 (6.61%)
|
<0.001
|
|
Bleeding
|
7 (36.84%)
|
9 (6.61%)
|
<0.001
|
|
Recurrence
|
2 (10.52%)
|
3 (2.2%)
|
0.055
|
|
Incontinence
|
1 (5.26%)
|
1 (0.73%)
|
0.101
|
|
Stenosis
|
1 (5.26%)
|
1 (0.73%)
|
0.101
|
Abbreviation: HPE, histopathology examination.
Correlation of Complications with Respect to Grade of Hemorrhoids and Muscle Fiber
Presence on Histopathology
Grade 2 hemorrhoids ([Table 5]) showed association between the groups only for pain on postoperative day 1 (p < 0.05) and rest all complications were statistically insignificant.
Table 5
Association of muscle fiber on early and late complications in Grade 2 group
|
Early complications
|
Muscle fiber in HPE
|
p-Value
|
|
Present [N = 3] (%)
|
Absent [N = 51] (%)
|
|
Pain day 1 (VAS)
|
< 4
|
1 (33.33)
|
47 (92.16)
|
0.032*
|
|
4–7
|
1 (33.33)
|
2 (3.92)
|
|
≥ 7
|
1 (33.33)
|
2 (3.92)
|
|
Pain day 3 (VAS)
|
< 4
|
3 (100)
|
51 (100)
|
–
|
|
Pain day 7 (VAS)
|
< 4
|
3 (100)
|
51 (100)
|
–
|
|
Urinary retention
|
Present
|
1 (33.33)
|
2 (3.92)
|
0.152
|
|
Absent
|
2 (66.67)
|
49 (96.08)
|
|
Bleeding
|
Present
|
0
|
1 (1.96)
|
0.999
|
|
Absent
|
3 (100)
|
50 (98.04)
|
|
Fecal urgency
|
Absent
|
3 (100)
|
51 (100)
|
–
|
|
Late complications
|
Present
|
Absent
|
p
-Value
|
|
Proctalgia
|
Present
|
0
|
3 (5.88)
|
0.999
|
|
Absent
|
3 (100)
|
48 (94.12)
|
|
Bleeding
|
Present
|
0
|
3 (5.88)
|
0.999
|
|
Absent
|
3 (100)
|
48 (94.12)
|
|
Incontinence
|
Absent
|
3 (100)
|
51 (100)
|
–
|
|
Recurrence
|
Absent
|
3 (100)
|
51 (100)
|
–
|
|
Stenosis
|
Absent
|
3 (100)
|
77 (100)
|
–
|
Abbreviations: HPE, histopathology examination; VAS, visual analog scale.
While evaluating for Grade 3 hemorrhoids ([Table 6]), there was statistical association between pain on postoperative days 1 and 2,
urinary retention, and bleeding in early complications (p < 0.05) and proctalgia and bleeding in late complications (p < 0.05), whereas Grade 4 hemorrhoids ([Table 7]) had only one parameter, postoperative pain on day 7, in early complications with
significant association.
Table 6
Association of muscle fiber on early and late complications in Grade 3 group
|
Early complications
|
Muscle fiber in HPE
|
p-Value
|
|
Present [N = 14] (%)
|
Absent [N = 77] (%)
|
|
Pain day 1 (VAS)
|
< 4
|
2 (14.29)
|
74 (96.10)
|
<0.0001a
|
|
4–7
|
6 (42.86)
|
1 (1.30)
|
|
≥ 7
|
6 (42.86)
|
2 (2.60)
|
|
Pain day 3 (VAS)
|
< 4
|
9 (64.29)
|
75 (97.40)
|
0.001a
|
|
4–7
|
5 (35.71)
|
2 (2.60)
|
|
Pain day 7 (VAS)
|
< 4
|
12 (85.71)
|
76 (98.70)
|
0.06
|
|
4–7
|
2 (14.29)
|
1 (1.30)
|
|
Urinary retention
|
Present
|
6 (42.86)
|
4 (5.19)
|
0.001a
|
|
Absent
|
8 (57.14)
|
73 (94.81)
|
|
Bleeding
|
Present
|
3 (21.43)
|
1 (1.30)
|
0.014a
|
|
Absent
|
11 (78.57)
|
76 (98.70)
|
|
Fecal urgency
|
Present
|
2 (14.29)
|
2 (2.60)
|
0.126
|
|
Absent
|
12 (85.71)
|
75 (97.40)
|
|
Late complications
|
Present
|
Absent
|
p
-Value
|
|
Proctalgia
|
Present
|
5 (35.71)
|
3 (3.90)
|
0.001a
|
|
Absent
|
9 (64.29)
|
74 (96.10)
|
|
Bleeding
|
Present
|
5 (35.71)
|
3 (3.90)
|
0.001a
|
|
Absent
|
9 (64.29)
|
74 (96.10)
|
|
Incontinence
|
Present
|
0
|
1 (1.30)
|
0.999
|
|
Absent
|
14 (100)
|
76 (98.70)
|
|
Recurrence
|
Present
|
0
|
1 (1.30)
|
0.999
|
|
Absent
|
14 (100)
|
76 (98.70)
|
|
Stenosis
|
Absent
|
14 (100)
|
77 (100)
|
–
|
Abbreviations: HPE, histopathology examination; VAS, visual analog scale.
Table 7
Association of muscle fiber on early and late complications in Grade 4 group
|
Early complications
|
Muscle fiber in HPE
|
p-Value
|
|
Present [N = 2] (%)
|
Absent [N = 8] (%)
|
|
Pain day 1 (VAS)
|
< 4
|
0
|
5 (62.50)
|
0.354
|
|
4–7
|
0
|
1 (12.50)
|
|
≥ 7
|
2 (100)
|
2 (25.00)
|
|
Pain day 3 (VAS)
|
< 4
|
0
|
7 (87.50)
|
0.068
|
|
4–7
|
2 (100)
|
1 (12.50)
|
|
Pain day 7 (VAS)
|
< 4
|
0
|
8 (100)
|
0.023a
|
|
4–7
|
2 (100)
|
0
|
|
Urinary retention
|
Present
|
2 (100)
|
2 (25.00)
|
0.139
|
|
Absent
|
0
|
6 (75.00)
|
|
Bleeding
|
Present
|
2 (100)
|
1 (12.50)
|
0.065
|
|
Absent
|
0
|
7 (87.50)
|
|
Fecal urgency
|
Present
|
2 (100)
|
2 (25.00)
|
0.139
|
|
Absent
|
0
|
6 (75.00)
|
|
Late complications
|
Present
|
Absent
|
p
-Value
|
|
Proctalgia
|
Present
|
2 (100)
|
3 (37.50)
|
0.440
|
|
Absent
|
0
|
5 (62.50)
|
|
Bleeding
|
Present
|
2 (100)
|
3 (37.50)
|
0.440
|
|
Absent
|
0
|
5 (62.50)
|
|
Incontinence
|
Present
|
1 (50.00)
|
0
|
0.198
|
|
Absent
|
1 (50.00)
|
8 (100)
|
|
Recurrence
|
Present
|
2 (100)
|
2 (25.00)
|
0.139
|
|
Absent
|
0
|
6 (75.00)
|
|
Stenosis
|
Present
|
1 (50.00)
|
1 (12.50)
|
0.369
|
|
Absent
|
1 (50.00)
|
7 (87.50)
|
Abbreviations: HPE, histopathology examination; VAS, visual analog scale.
Discussion
Hemorrhoids are usually considered one of the most common anorectal disorders. Patients
often tend to hesitate to seek treatment resulting in disease progression due to social
taboos associated with hemorrhoids.
PPH first described by Longo in 1998 was perceived globally due to its advantages,
and many case series, meta-analyses, and systemic reviews showed that it is both safe
and effective and is better than conventional hemorrhoidectomy in terms of postoperative
pain and early return to work.[9]
[10] However, in recent studies, long-term follow-up assessing complications of stapled
hemorrhoidectomy led to suspicion surrounding the safety and cost-effectiveness of
this procedure compared with other techniques available for hemorrhoidectomy.[11] In a systemic review conducted by Porrett et al[6] where 78 studies with follow-up periods ranging from 1 month to 7 years, involving
14,234 patients, researchers reported postoperative complications of stapled hemorrhoidectomy,
the incidence rates of early complications widely ranged between 2.3 and 52.5% with
a median value of 16.1%, and the incidence rates of late complications ranged between
2.5 and 80% with a median value of 23.7%. The aforementioned studies also reported
that the cause of complications could be attributed to the presence of muscle fibers
in the resected doughnut.
In a study conducted by Stolfi et al,[4] where stapled hemorrhoidectomy was compared with the Milligan–Morgan method in 200
patients (100 patients in each group), no difference in postoperative pain was observed
between the two groups on the first 2 days, but in the next 6 consecutive days, patients
who received stapled hemorrhoidectomy demonstrated significantly less pain.[12] In this study, a similar pattern of pain scores was observed with only five (3.2%)
patients presenting with residual pain on postoperative day 7 requiring analgesics
for pain control. However, an association was found between higher pain scores and
the presence of muscle fibers on histopathology, and this association was statistically
significant.
Urinary retention is a common complication after anorectal surgery with rates ranging
from 3 to 50%. Most studies reported a rate of 15%. Postoperative urinary retention
is multifactorial with contributions from irritation/blockade of pelvic nerves and
pain-evoked reflexes. Ommer et al[13] reported similar observations. In a study conducted by Sultan et al involving more
than 150 patients, despite exhibiting a postoperative morbidity rate of as low as
9.3% and high patient satisfaction in the postoperative period following stapled hemorrhoidopexy,
acute urinary retention accounted for 7.3%.[5] In this study, 10.96% of the patients exhibited urinary retention; however, the
incidence of urinary retention in the patients presenting with muscle fibers in histopathology
was ∼47%.
The incidence of early postoperative bleeding ranges from 4.2 to 7.5%.[14] This complication is commonly due to arteriolar bleeding along the staple line or
folding of excessive mucosa into the staple line. This study reported an incidence
rate of 5.16%, and early bleeding was significantly associated with the presence of
muscle fibers in histopathology examination. In 2010, Sultan et al observed that using
staples with a smaller staple bite of 0.75 to 1.5 mm (PPH-03), instead of its precedent
of 1.2 to 2.5 mm (PPH-01), led to better compression of rectal tissue and bleeding
vessels, reducing the incidence of early postoperative bleeding.[15]
The reported incidence rates of early fecal urgency range from 0 to 25% with a median
of 8.28%.[16] The etiology of this complication could be attributed to muscle contraction in response
to nerve or muscle irritation, which may decrease rectal compliance. Fecal urgency
usually disappears in the first few weeks after surgery in most cases.[5] In this study, 5.16% of the patients presented with fecal urgency with spontaneous
recovery by the end of the first postoperative week, and this complication was associated
with the presence of muscle fibers on histopathologically examination.
Most complications are either related to improper selection of cases for surgery or
technical errors either by the man behind the machine or the machine itself. The earliest
study was conducted in year 2000 by Cheetham et al involving 22 cases of stapled hemorrhoidectomy,
including 7 cases of pilot study and 15 cases of randomized controlled study with
open hemorrhoidectomy. They observed persistent severe pain and fecal urgency in several
patients after stapled hemorrhoidectomy, followed by conventional open surgery. The
mechanism behind the complications was unclear, and muscle fiber incorporation in
the doughnut may have contributed.[17] Similar studies by Ielpo et al reported that 14.3% of patients exhibited pain lasting
more than 2 weeks. They correlated that this postoperative pain to additional hemostatic
stitches, causing ischemic pain, and endoanal ultrasound demonstrated retained staples
with inflammation around them. Thus, Ielpo et al recommended carefully applying hemostatic
stitches to avoid inclusion of muscle fibers and complete burrowing the staples.[18]
Postoperative pain is determined by both the ideal placement of suture in relation
to the dentate line and the depth of purse-string suture taken. In a study by Plocek
et al in 2006, the height of staples seemed to be correlated with the duration of
narcotic pain management and interval to return to work.[19] In 2007, Ganio et al observed that the staple line being well above the dentate
line is the cause of elevated sphincter muscle tone, causing chronic pain in the postoperative
period.[20] The incorporation of smooth muscles into the doughnut and the induction of the inflammatory
process in the staple line may increase the incidence of postoperative pain. The formation
of fibrosis near the staple line may chronically stimulate the nerve spindles located
over the puborectalis muscle, causing pudendal neuropathy with chronic proctalgia
and fecal urgency.[4]
The cause for late bleeding, which occurs usually between postoperative weeks 6 and
16, may be attributed to inflammation around the staple line or its rejection or the
presence of inflammatory polyps along the staples, requiring local remedial measures.[15] In this study, we found that late postoperative bleeding and proctalgia were found
in 10.32% of the patients, and the difference in the incidence of these complications
between patients with and without muscle fibers was statistically significant.
The recurrence rate following stapled hemorrhoidopexy was 11%, with ∼10% of patients
requiring reoperation.[21] The recurrence rate after stapled hemorrhoidopexy (8.5%) was significantly higher
than that after manual hemorrhoidectomy (1.5%).[22] Riss et al conducted a long-term study with a mean follow-up duration of 48 months
and reported that Longo's technique of stapled hemorrhoidopexy demonstrated no negative
impact with significant improvements in evacuation scores.[23] In 2013, Hong et al concluded that the incorporation of muscle fibers in the resected
doughnuts after stapled hemorrhoidopexy may affect anorectal manometry results; however,
they did not find any significant differences in the postoperative outcomes.[24] The incidence of stenosis after stapled hemorrhoidopexy ranges from 0 to 8%, and
most cases resolve with conservative management (i.e., outpatient dilatation), rarely
requiring surgical intervention.[25] In this study, we found that the rate of recurrence was 3%, the rate of incontinence
was 2%, and the rate of stenosis was less than 1.5%. When comparing Group A with Group
B, the results were statistically insignificant.
In November 2002, George et al conducted a study examining the histopathology of resected
specimens obtained from 26 consecutive patients who underwent stapled hemorrhoidectomy.[26] The specimens were examined for the type of mucosa and muscle fibers in detail and
observed for clinical outcomes postoperatively. They concluded that the level of purse-string
suture and depth determined the presence of stratified epithelium or internal anal
muscle fibers, and surgeons should be aware of the importance of the technique to
avoid injury to the internal anal sphincter.
Some life-threatening early complications have been documented following stapled hemorrhoidopexy,
such as pelvic sepsis, rectal perforation, Fournier's gangrene, acute hemorrhage,
rectopneumoperitoneum, rectal stricture, and rectovaginal fistula, which brought disrepute
to this technique compared with other available modalities.[27] Most complications were attributed to technical error or wrong indications.
While including the grade of hemorrhoids for statistical evaluation, the inclusion
of muscle fiber was pivotal in giving rise to complications for Grade 3 hemorrhoids
patients and not much of impact for Grades 2 and 4 hemorrhoids.
With careful selection of cases and proper technique execution, stapled hemorrhoidopexy
remains to be an accepted modality for treating hemorrhoids.[28] The overall complication rates in this study were low, accounting for 16.7% of the
patients among whom 61.5% exhibited muscle fibers in the doughnut specimens. Additionally,
early complications were significantly associated with the presence of muscle fibers.
No long-term residual or life-threatening postoperative complications were observed
in this study.
Endorectal ultrasound evaluation would have given accurate analysis of fragmentation
of anorectal muscles, however, due to the lack of facilities for endorectal ultrasound
in the institution is the drawback of this study.
Conclusion
The inclusion of muscle fibers while executing stapled hemorrhoidopexy can lead to
complications especially in Grade 3 hemorrhoids. The technique of taking the purse-string
sutures is purely subjective and surgeon dependent. Sending histopathology specimens
would provide feedback to the operating surgeon for further refining the technique
of taking purse-string sutures with optimal depth to avoid inadvertent inclusions
of muscle fibers.
