Stapling procedure for haemorrhoids versus Milligan-Morgan haemorrhoidectomy: randomised controlled trial

Abstract

Surgical haemorrhoidectomy has a reputation for being a painful procedure for a fairly benign disorder. The circular transanal stapled technique for the treatment of haemorrhoids has the potential to achieve a less painful rectal procedure in place of ablative perianal surgery. We compared the short-term outcome of the circular stapled procedure for haemorrhoids with current standard surgery in a randomised controlled trial. Forty patients admitted for surgical treatment of prolapsing haemorrhoids were randomly assigned to Milligan-Morgan haemorrhoidectomy (n=20) or the circular stapled procedure. Under general anaesthesia patients underwent standardised diathermy excision haemorrhoidectomy or had a circumferential doughnut of rectal mucosa and submucosa above the dentate line excised and closed with a standard circular end-to-end stapling device. All patients received standardised preoperative and postoperative analgesic and laxative regimens. Patients completed linear analogue pain charts each day and were interviewed at 1, 3 and 6-10 weeks postoperatively. Summary measures of average pain experience were calculated from 10 cm linear analogue pain scores and were used as the primary outcome measure. The stapled group had shorter anaesthesia time (median 18 [range 9-25] vs 22 mins). Average pain in the stapled group was significantly lower than it was in the Milligan-Morgan group (2.1 [0.2-7.6] vs. 6.5 [3.1-8.5], 95.1% CI difference medians 1.9-4.7, p<0.00001. Mann-Whitney U test). Average pain relative to what the patient expected was also significantly less in the stapled group (-2.8 [-4.4 to 1.3] vs. 0·7 [-1.8 to 3.4]. Hospital stay and time to first bowel motion were not significantly different between groups. Return to normal activity was significantly shorter in the stapled group (17 [3-60] vs 34 . Early and late complications, patientassessed symptom control, and functional outcome appear similar after short-term follow-up. The circular stapled technique offers a significantly less painful alternative to Milligan-Morgan haemorrhoidectomy and is associated with an earlier return to normal activity. Early symptom control and functional outcome appear similar. However, long-term symptomatic and functional outcome need further study. Invited commentThis is one of the first papers published on a randomised trial comparing stapled procedure versus Milligan-Morgan for haemorrhoids. Twenty patients were included in both arms and were operated in general anesthesia with identical premedications, postoperative drugs as well as standard postoperative nursing care. Patients were not aware of which procedure they underwent. The primary outcome measure was postoperative pain. Secondary out-come measures were expected pain, anaesthesia time, use of analgesia, time to first bowel motion and time until return to normal activity.Patients had to register daily using an analogue scale if the pain they experienced was better or worse to what they had expected. Pain is a very subjective feeling and haemorrhoidectomy has a b...

Prospective randomised multi-centre trial comparing the clinical efficacy, safety and patient acceptability of circular stapled anopexy with closed diathermy haemorrhoidectomy

“…Our trial confirms the reduction in postoperative pain following SA reported by previous researchers7 8 10 11 and demonstrates a reduced analgesic requirement and a significantly earlier total pain resolution in these patients. Despite this significantly reduced pain, the patients who underwent SA in our trial did not return to work earlier and had a similar day surgery rate as the haemorrhoidectomy patients.…”

“…The absence of an external wound together with its proven reduced postoperative pain7 8 offers scope for early rehabilitation and may result in better patient satisfaction and improved uptake of day-case operations. Furthermore, the principles of reduction of the prolapsed anal cushion instead of its excision, interruption of the haemorrhoidal arterial pedicles during stapling, and control of the external components by an indirect pulling-up effect and reversing the effects of prolapse caused by vascular disruption may provide a more rational approach to addressing the disease in a broader group of patients, and may achieve a better physiological outcome 6.…”

How to treat haemorrhoids

“…10 11 This technique potentially provides a tool for reducing some of the complications associated with conventional surgery, provided that the operator has the technical experience. However, stapling increases operative costs; advanced surgical skills are necessary; and there is a learning curve 12.…”

Posterior perineal block with ropivacaine 0.75% for pain control during and after hemorrhoidectomy

“…Surgical approaches also need re-evaluation, taking into account the intensity of patients' pain. Endorectal mucosectomy is a less painful surgical technique, 23,24 and further prospective studies are necessary to evaluate its effectiveness in association with PPB for postoperative analgesia. Further studies may be also useful to compare pre-and postoperative PPB and to test the hypothesis of a pre-emptive analgesic effect.…”