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Treatment of grade III and IV haemorrhoidal disease with PPH or THD. A randomized trial on postoperative complications and short-term results

  • Sebastiaan FestenEmail author
  • M. J. van Hoogstraten
  • A. A. W. van Geloven
  • M. F. Gerhards
Original Article

Abstract

Purpose

Haemorrhoidal disease is a frequently occurring entity in the western world. The Procedure for prolapse and haemorrhoids (PPH) and transanal haemorrhoidal dearterialisation (THD) are the most important surgical treatments that respect normal anal anatomy. This is the first randomized trial that compares both techniques in the treatment of grade III and IV haemorrhoids.

Methods

Patients with grade III or IV haemorrhoids were randomized between PPH and THD. Patients were seen after 1 week, 3 weeks and 6 weeks postoperatively. Primary endpoint was resolved symptoms 6 weeks postoperatively. Secondary endpoints were pain, measured with a visual analogue scale (VAS) after 1 day, 1 week and 3 weeks, and complications

Results

Eighteen patients were allocated to PPH versus 23 to THD. Success rates after 6 weeks were 83% in the PPH group versus 78% in the THD group. VAS scores were significantly lower after 1 day and 1 week in the THD group, but equalled out after 3 weeks. Twelve percent of the patients after PPH and 4% after THD needed an urgent readmission to treat an acute bleeding. Overall complication rates did not differ significantly.

Conclusion

Both PPH and THD are safe treatments for grade III and IV haemorrhoids with acceptable complication rates and good short-term results. THD might be the preferred treatment because it carries the similar complication rate and short-term results, but results in less postoperative pain when compared with PPH. Moreover, it is a less invasive, more easily learned and less costly procedure.

Keywords

Haemorrhoids Prolapse Doppler-guided haemorrhoidal artery ligation (DGHAL) Transanal haemorrhoidal dearterialisation (THD) Procedure for prolpase and haemorrhoids (PPH) 

Reference

  1. 1.
    Kaidar-Person O, Person B, Wexner SD (2007) Hemorrhoidal disease: a comprehensive review. J Am Coll Surg 204(1):102–117CrossRefPubMedGoogle Scholar
  2. 2.
    Thomson WH (1975) The nature of haemorrhoids. Br J Surg 62(7):542–552CrossRefPubMedGoogle Scholar
  3. 3.
    MacRae HM, McLeod RS (1997) Comparison of hemorrhoidal treatments: a meta-analysis. Can J Surg 40(1):14–17PubMedGoogle Scholar
  4. 4.
    Longo A (2002) Stapled anopexy and stapled hemorrhoidectomy: two opposite concepts and procedures. Dis Colon Rectum 45(4):571–572CrossRefPubMedGoogle Scholar
  5. 5.
    Pescatori M, Aigner F (2007) Stapled transanal rectal mucosectomy ten years after. Tech Coloproctol 11(1):1–6CrossRefPubMedGoogle Scholar
  6. 6.
    Ganio E, Altomare DF, Milito G, Gabrielli F, Canuti S (2007) Long-term outcome of a multicentre randomized clinical trial of stapled haemorrhoidopexy versus Milligan-Morgan haemorrhoidectomy. Br J Surg 94(8):1033–1037CrossRefPubMedGoogle Scholar
  7. 7.
    Tjandra JJ, Chan MK (2007) Systematic review on the procedure for prolapse and hemorrhoids (stapled hemorrhoidopexy). Dis Colon Rectum 50(6):878–892CrossRefPubMedGoogle Scholar
  8. 8.
    Goldstein SD, Meslin KP, Mazza T, Isenberg GA, Fitzgerald J, Richards A et al (2007) Stapled hemorrhoidopexy: outcome assessment. Am Surg 73(7):733–736PubMedGoogle Scholar
  9. 9.
    Giordano P, Gravante G, Sorge R, Ovens L, Nastro P (2009) Long-term outcomes of stapled hemorrhoidopexy vs conventional hemorrhoidectomy: a meta-analysis of randomized controlled trials. Arch Surg 144(3):266–272CrossRefPubMedGoogle Scholar
  10. 10.
    Thaha MA, Campbell KL, Kazmi SA, Irvine LA, Khalil A, Binnie NR et al (2009) Prospective randomised multi-centre trial comparing the clinical efficacy, safety and patient acceptability of circular stapled anopexy with closed diathermy haemorrhoidectomy. Gut 58(5):668–678CrossRefPubMedGoogle Scholar
  11. 11.
    Bona S, Battafarano F, Fumagalli RU, Zago M, Rosati R (2008) Stapled anopexy: postoperative course and functional outcome in 400 patients. Dis Colon Rectum 51(6):950–955CrossRefPubMedGoogle Scholar
  12. 12.
    Ceci F, Picchio M, Palimento D, Cali B, Corelli S, Spaziani E (2008) Long-term outcome of stapled hemorrhoidopexy for Grade III and Grade IV hemorrhoids. Dis Colon Rectum 51(7):1107–1112CrossRefPubMedGoogle Scholar
  13. 13.
    Fueglistaler P, Guenin MO, Montali I, Kern B, Peterli R, von Flue M et al (2007) Long-term results after stapled hemorrhoidopexy: high patient satisfaction despite frequent postoperative symptoms. Dis Colon Rectum 50(2):204–212CrossRefPubMedGoogle Scholar
  14. 14.
    Kanellos I, Zacharakis E, Kanellos D, Pramateftakis MG, Tsachalis T, Betsis D (2006) Long-term results after stapled haemorrhoidopexy for third-degree haemorrhoids. Tech Coloproctol 10(1):47–49CrossRefPubMedGoogle Scholar
  15. 15.
    Zacharakis E, Kanellos D, Pramateftakis MG, Kanellos I, Angelopoulos S, Mantzoros I et al (2007) Long-term results after stapled haemorrhoidopexy for fourth-degree haemorrhoids: a prospective study with median follow-up of 6 years. Tech Coloproctol 11(2):144–147CrossRefPubMedGoogle Scholar
  16. 16.
    Brown S, Baraza W, Shorthouse A (2007) Total rectal lumen obliteration after stapled haemorrhoidopexy: a cautionary tale. Tech Coloproctol 11(4):357–358CrossRefPubMedGoogle Scholar
  17. 17.
    Brusciano L, Ayabaca SM, Pescatori M, Accarpio GM, Dodi G, Cavallari F et al (2004) Reinterventions after complicated or failed stapled hemorrhoidopexy. Dis Colon Rectum 47(11):1846–1851CrossRefPubMedGoogle Scholar
  18. 18.
    Cipriani S, Pescatori M (2002) Acute rectal obstruction after PPH stapled haemorrhoidectomy. Colorectal Dis 4(5):367–370CrossRefPubMedGoogle Scholar
  19. 19.
    Filingeri V, Gravante G (2005) The last images. Pneumoretroperitoneum, pneumomediastinum and subcutaneous emphysema of the neck after stapled hemorrhoidopexy. Tech Coloproctol 9(1):86CrossRefPubMedGoogle Scholar
  20. 20.
    Pescatori M, Gagliardi G (2008) Postoperative complications after procedure for prolapsed hemorrhoids (PPH) and stapled transanal rectal resection (STARR) procedures. Tech Coloproctol 12(1):7–19CrossRefPubMedGoogle Scholar
  21. 21.
    Ripetti V, Caricato M, Arullani A (2002) Rectal perforation, retropneumoperitoneum, and pneumomediastinum after stapling procedure for prolapsed hemorrhoids: report of a case and subsequent considerations. Dis Colon Rectum 45(2):268–270CrossRefPubMedGoogle Scholar
  22. 22.
    Sileri P, Stolfi VM, Franceschilli L, Perrone F, Patrizi L, Gaspari AL (2008) Reinterventions for specific technique-related complications of stapled haemorrhoidopexy (SH): a critical appraisal. J Gastrointest Surg 12(11):1866–1872CrossRefPubMedGoogle Scholar
  23. 23.
    Wong LY, Jiang JK, Chang SC, Lin JK (2003) Rectal perforation: a life-threatening complication of stapled hemorrhoidectomy: report of a case. Dis Colon Rectum 46(1):116–117CrossRefPubMedGoogle Scholar
  24. 24.
    Morinaga K, Hasuda K, Ikeda T (1995) A novel therapy for internal hemorrhoids: ligation of the hemorrhoidal artery with a newly devised instrument (Moricorn) in conjunction with a Doppler flowmeter. Am J Gastroenterol 90(4):610–613PubMedGoogle Scholar
  25. 25.
    Dal Monte PP, Tagariello C, Sarago M, Giordano P, Shafi A, Cudazzo E et al (2007) Transanal haemorrhoidal dearterialisation: nonexcisional surgery for the treatment of haemorrhoidal disease. Tech Coloproctol 11(4):333–338CrossRefPubMedGoogle Scholar
  26. 26.
    Faucheron JL, Gangner Y (2008) Doppler-guided hemorrhoidal artery ligation for the treatment of symptomatic hemorrhoids: early and three-year follow-up results in 100 consecutive patients. Dis Colon Rectum 51(6):945–949CrossRefPubMedGoogle Scholar
  27. 27.
    Wilkerson PM, Strbac M, Reece-Smith H, Middleton SB (2009) Doppler-guided haemorrhoidal artery ligation: long-term outcome and patient satisfaction. Colorectal Dis 11(4):394–400CrossRefPubMedGoogle Scholar
  28. 28.
    Walega P, Scheyer M, Kenig J, Herman RM, Arnold S, Nowak M et al (2008) Two-center experience in the treatment of hemorrhoidal disease using Doppler-guided hemorrhoidal artery ligation: functional results after 1-year follow-up. Surg Endosc 22(11):2379–2383CrossRefPubMedGoogle Scholar
  29. 29.
    Jayaraman S, Colquhoun PH, Malthaner RA (2007) Stapled hemorrhoidopexy is associated with a higher long-term recurrence rate of internal hemorrhoids compared with conventional excisional hemorrhoid surgery. Dis Colon Rectum 50(9):1297–1305CrossRefPubMedGoogle Scholar
  30. 30.
    Schmidt J, Dogan N, Langenbach R, Zirngibl H (2009) Fecal urge incontinence after stapled anopexia for prolapse and hemorrhoids: a prospective, observational study. World J Surg 33(2):355–364CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag 2009

Authors and Affiliations

  • Sebastiaan Festen
    • 1
    Email author
  • M. J. van Hoogstraten
    • 1
  • A. A. W. van Geloven
    • 1
  • M. F. Gerhards
    • 1
  1. 1.Departement of SurgeryOnze Lieve Vrouwe GasthuisAmsterdamThe Netherlands

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