PPH en Suramerica. 15th Annual Colorectal Disease Symposium, Cleveland Clinic Florida-13/02/2004
”Hemorrhoid Treatments and PPH In 2004:
Jorge Larach, MD
Clinica Las Condes, Santiago, Chile
Pain is a perfect misery
“ like passing bits of broken glass”
In recent years, the surgical treatment of hemorrhoids has been less frequently performed in
several centers, not only because it is recognized as a painful operation by the public, but
also because the treatment of early stages (grade I or II) can be done with less invasive
techniques, like rubber band ligature, infrared coagulation or sclerotherapy, on ambulatory
settings. However, these alternatives are not valid in advanced stages (grade III or IV).1
The treatment for advanced stages of the disease (III and IV) is hemorrhoidectomy, a
surgical procedure that involves excision of the hemorrhoidal plexus, anoderm and perianal
skin with multiple suture lines on a highly sensitive area.
Excisional hemorrhoidectomy is an operation that if well performed, cures the disease
almost without mortality, although it is usually very painful and has a prolonged healing
period that lasts no less than 30 days.
The treatment of hemorrhoids has always been focused on how to destroy the anal
cushions, and the discussion has been centered in which is the best way to do it: excision,
heat, strangulation, linear staplers2, Harmonic scalpel3, Ligasure4, etc.
Modifications to reduce postoperative pain have included: closed hemorrhoidectomy5, the
addition of lateral internal sphincterotomy6, anal dilatation, use of oral metronidazole7 and
anal sphincter relaxants.
Any advances in this same direction will provide only very moderate benefits.
The challenge is to have patients free of pain, with at least equivalent results to excisional
operations, minimal complications, and reasonable costs.
The concept of the hemorrhoidal disease not as a vascular disease, but as a prolapsing
disease of the structures in the anal canal 8, is the rationale of the surgical treatment
developed by A. Longo.
This treatment consists of the relocation of prolapsing hemorrhoids to their anatomic place
within the anal canal by means of a circumferential stapler.9,10 It may also imply
interruption of blood flow by stapling the different submucosal branches of hemorrhoidal
This operation should not be called hemorrhoidectomy, but anopexy11, hemorrhoidopexy or
mucosectomy, because there is no full resection of hemorrhoids.
After being use for several years, it has become a well established procedure that according
to comparative clinical trials12-19, has shown advantages such as minimal postoperative
pain, early return to normal activities, and scarce morbidity.
But still, additional comparative trials are required between this procedure and excisional
hemorrhoidectomy to determine its true long-term therapeutic value.20
Meanwhile, we have obtained some answers to the questions formulated by Seow-Choen in
2001, about indication, postoperative pain, complications and costs of the operation. 21
The experience with the circular stapled mucosectomy in Latin America started in the year
2000 and until July 2002, 1180 cases had been performed by a group of 30 surgeons.22
Nowadays probably more than 3000 patients have been operated by multiple groups,
mainly in Brazil >100023, Argentina >800, Chile >600, and Mexico >900.
We have been performing this operation since the year 2000, in patients with hemorrhoids
grade III, hemorrhoids grade IV without chronic (fixing) edema, and patients with
associated rectocele and hemorrhoids. Ocassionally it has been used in cases in association
with sphincterotomy and fistulotomy.
In the exclusion criteria we have considered acute hemorrhoidal disease (thrombosis),
previous hemorrhoidal or perianal surgery, bleeding disorders, aspirin ingestion, psychiatric
disorders, immunosuppression, and incontinence.
In relation to technical aspects, we use the lithotomy position. The correct placement of the
purse string suture is essential for the success. When it is too high the reduction of the
prolapse is incomplete, if too low, the pain is increased and squamous epithelium may be
found in the surgical specimen.24 Stitches must take mucosa and submucosa avoiding gaps
in the suture line. Lately we have been performing the modification proposed by the
Singapore group to obtain a more symmetrical doughnut.25 After the instrument is
withdrawn the staple line is inspected for obtaining an accurate hemostasis, and any
detectable bleeding area is sutured with 3/0 reabsorbable material (vicryl). Hemostasis is
usually part of the operation, and should not be considered a complication.
Something between 33.3 and 91 percent of the patients required a hemostatic suture after
firing the stapler.22
It has been established in randomized (Table 1) and non-randomized studies that stapling
dramatically decreases the level of postoperative pain.
Less analgesia was required following PPH, with very different schemes, as shown in most
comparative studies. (Table 1) 12-19
Sometimes stapling led to greater pain in the immediate postoperative period, but 2 weeks
after surgery, pain scores and also rectal discharge were significantly lower in the PPH
The variables that were associated with postoperative pain level during the first 24 hours
were the type of resected epithelium, and the staple line level.24 The inclusion of squamous
epithelium in the resected specimen was identified as a pain related factor, because of the
presence of sensory nerve endings for touch, pain, and temperature in the squamous and
transitional areas of the anal canal. Patients in whom the staple line level was at 20 mm or
more above the dentate line (with no squamous epithelium resected) reported a significant
lower postoperative pain level in the VAS. (Visual analog scale = VAS 0 = no pain and 10
= maximum pain) 24
We would like to emphasize the advantage of PPH, in the almost complete elimination of
perianal wounds treatment, in the postoperative period. Sometimes, anal wounds can be a
significant problem after conventional hemorrhoidectomy.
In one trial, patients needed wound care at home in 75% of Milligan-Morgan operations vs.
only 2% of the stapled group.26
Length of disability
There is a significantly shorter length of disability with PPH. This has been more evident in
patients like medical doctors, lawyers, and self-employed workers.
Days of disability were significantly reduced for PPH vs conventional hemorrhoidectomy
in most studies.12,15,17
Minimal wound care and shorter length of disability, may have a positive impact on both,
perioperative costs and postoperative satisfaction with the procedure.
In early postoperative stages, the complications most frequently reported were acute
bleeding, acute urine retention, and thrombosis.
Late complications included: fecal urgency without episodes of incontinence, anal pruritus,
anal stricture, thrombosis, and rarely dyspareunia. (Table 2)
The total percentage of complications associated with PPH was between 15 and 17.5
percent, 14,24 with a ten-fold risk of developing some late complications when squamous
epithelium was resected.24
The most frequent postoperative symptom at 2 month was residual minor bleeding episodes
(9 percent), and at > 6 month follow up (21 percent presented some symptoms), once again
bleeding was the most frequent (14 percent), followed by the perception of skin tags, and
pruritus. However, there was no association between persistent bleeding and the level of the
stapling line. 24
The incidence of stenosis up to 1 year follow-up, were not statistically different in
comparative studies.15,17 Stenosis after PPH appears like a diaphragm on the lower rectum,
and easier to dilate on digital examination than after conventional hemorrhoidectomy, in
which general anaesthesia is often needed.
One of the advantages of PPH is presumed to provide a better preservation of fecal
continence. Venous cushions are left intact, and mucosal sensitivity is maintained at the
level of the transitional zone, whereas these tissues are excised in the conventional
hemorrhoidectomy and replaced by scars.
Theoretically, anal dilatation performed to reach and staple the lower rectum can cause
stretching lesions of the internal sphincter, resulting in increased risk of anal incontinence.
It has been demonstrated that PPH does not affect the morphology and function of the
internal sphincter, in the long term follow up, on the contrary, the sensitivity of the anal
canal can improve in patients with preoperative sensory impairment.31
Comparative studies that measured anal resting and squeeze pressures showed no
significant functional variations between the measurements in both groups. 14,16,17
We have no data in Latin America of serious complications similar to those reported by
authors in Europe and Asia, with severe pain caused by ruptured staple line, rectal
perforations, retrorectal hematomas, retroperitoneal sepsis, and lethal Fournier´s gangrene.
32-34 These serious complications are not exclusive of PPH, and there have been reports in
the literature of severe perineal and pelvic sepsis after conventional hemorrhoidectomy, and
also with rubber band ligation, and sclerotherapy.35-37
Recurrence of symptoms associated with the disease was reported in up to 5% of patients.
At a mean follow up of 16 months, prolapse was more common in the stapled group than in
the excisional hemorrhoidectomy group. 16
Satisfaction with PPH
In comparative studies, patients from the PPH groups perceived a higher rate of operative
success, and also a significantly higher number of these patients stated that they would be
willing to undergo the same procedure.
The surgeons were also satisfied with the procedure (Table 3) 22
In other studies, the low degree of satisfaction (manifested by 3 % of patients) was the
result of the lack of change of the external hemorrhoidal component. 24
Patients with a significant external component may benefit more from another technique.
PPH requires the use of an imported kit relatively expensive in our countries.
PPH kit costs in our institution about US $ 460, and in Argentina US $ 430.
This is probably the reason why the procedure is in conflict with a more generalized use.
The OR time required with the PPH procedure was significantly shorter than in
conventional hemorrhoidectomy, in our experience, as in other studies.12,14,15,17 This could
be an important factor in those institutions that charge by the OR’s time use.
Hospital stay is shorter in PPH groups, resulting in significant cost savings,38 but this
advantage is highly dependable on the institutional policies regarding ambulatory
procedures settings. (ambulatory excisional hemorrhoidectomy)
In a regional study, 22 93.2 % of PPH patients required hospital stay for 24 hours or less.
We have analyzed our total institutional expenses comparing excisional hemorrhoidectomy
and PPH operations, for the last two years. In spite of the high cost of the stapler (>US$
400), there was no statistical differences in the final hospital costs (P = 0.21), probably
because of the shorter length of stay in the PPH group.
This has also been described in some studies, in which cumulative economic cost (surgical
materials and hospital stay) did not reach statistic significance17, and increased instrument
cost is offset by the shorter convalescence period. 14 (Table 4).
When patients are informed of the advantages of PPH related to pain, and are given a
choice of paying the additional cost of the stapler, they always opt for it.
Besides waiting for careful and comparable studies on long-term results, probably other
questions will arise:
Which is the best treatment for associated skin tags?
Is stapling an alternative to rubber band ligature treatment in hemorrhoids grade II?
Will it be cost effective in grade II?
Is it possible to use PPH safely, in association with other simultaneous anal procedures?
Would it be effective and safe to use PPH once more in recurrences?
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