2006 by the Société Internationale de Chirurgie World J Surg (2006) 30: 1311–1315

Published Online: 13 June 2006 DOI: 10.1007/s00268-005-0484-0

Rectal Stenosis after Procedures for Prolapse

and Hemorrhoids (PPH)—A Report from China
Liqin Yao, MD, Yunshi Zhong, MD, Jianmin Xu, MD, PhD, Meidong Xu, MD, PhD,
Pinghong Zhou, MD, PhD
Department of General Surgery, Zhongshan Hospital, Fudan University Medical Center, Shanghai 200032,
People’s Republic of China

Abstract
Objectives: After it was introduced in China in 2000, the surgical procedure for prolapse and
hemorrhoids (PPH) has become a widely accepted for third- and fourth-degree hemorrhoids.
Stenosis of the lower rectum is one of the delayed complications. In order to evaluate this specific
problem following PPH, we reviewed our data with special reference to potential predictive factors
or stenotic events.
Methods: A retrospective analysis of 554 consecutive patients that underwent PPH from July 2000
to December 2004 was performed. Only patients with follow-up check were evaluated; therefore
65 patients (11.7%) were lost to follow-up, and the analysis therefore includes 489 patients with a
mean follow-up of 324 days (– 18 days). For statistical analysis, the groups with and without
stenosis were evaluated using the chi-square test; using the Kaplan-Meier statistic, the actuarial
incidence for rectal stenosis was plotted.
Results: Rectal stenosis was observed in 12 patients (2.5%) in whom the median time to stenosis
was 125 (89  134) days. All patients complained of obstructive defecation and underwent
strictureplasty with electrocautery or balloon dilation through colonoscopy. A statistical analysis
revealed that two factors were significantly more prevalent among patients with stenosis: prior
sclerosis therapy for hemorrhoids (P = 0.02) and severe postoperative pain (P = 0.003). Other
factors, such as gender (P = 0.32), prior surgery for hemorrhoids (P = 0.11), histological evidence
of squamous skin (P = 0.77) or revision (P = 0.53) showed no significance.
Conclusions: Rectal stenosis is an uncommon event after PPH. Early stenosis will occur within the
first 4 months after surgery. In most cases, the stenosis can be cured through colonoscopy
surgery. Predictive factors for stenosis are previous sclerosis therapy for hemorrhoids and severe
postoperative pain.

A fter it was introduced in China in 2000, the surgical

procedure for prolapse and hemorrhoids (PPH) has
become widely accepted for the treatment of third- and
fourth-degree hemorrhoids. Compared to conventional
hemorrhoidectomy, the reduction of postoperative pain
and the shorter hospital stay make PPH a recommended
Correspondence to: Yunshi Zhong, Department of General Surgery,
Zhongshan Hospital, Fudan University Medical Center, Shanghai
200032, People’s Republic of China, e-mail: zhong780124@sina.com
surgical procedure. Between July 2000 and December
2004, more than 10,000 PPH were performed.1 Although
a recently published review2 demonstrated that there is
no conclusive evidence for it, PPH can be regarded as a
well-established procedure with relatively low complica-
tion rates.3 However, the complications that do develop
can be severe.4–6 Stricture of the lower rectum is re-
garded as an uncommon complication after PPH.7 How-
ever, when a stenosis occurs this causes prolonged
treatment and eventually additional treatment.
1312 Yao et al.: Rectal Stenosis after PPH Operations

To evaluate the results, we reviewed our retrospective

data with special reference to rectal stenosis and poten-
tial predictive factors for its occurrence.

MATERIALS AND METHODS

Between July 2000 and December 2004, a total of 554

patients were treated surgically for third- and fourth-de-
gree hemorrhoids at the Department of General Surgery
at Zhongshan Hospital. Patients were examined at 1
month, 6 months, and 1 year after surgery. 65 patients
(11.7%) who were not seen at follow-up were excluded
from the retrospective analysis. Consequently, for this
study we reviewed the data of the 489 patients who
underwent PPH and completed the follow-up. The mean
follow-up was 324 days (– 18 days).
The PPH operation was regularly performed under Figure 1. The actuarial complication rate calculated according
sacroiliac anesthesia; patients were placed in the lithotomy to the Kaplan-Meier life-table method.
position. Two purse-string sutures were placed, and the
could not be passed by a finger. Ten patients underwent
PPH 33 mm Ethicon Endosurgery stapler (PPH 01) was
balloon dilation through colonoscopy, and the other two
used. Additional stitches with monofilament resorbable
patients underwent strictureplasty with electrocautery
sutures for hemostasis were placed at regular intervals
under colonoscopy.
around the stapled ring. Patients left the hospital as soon as
they felt comfortable; no day-surgery was performed.
Patients were invited for follow-up checks after Patient Characteristics
1 month, 3 months, and 1 year. Those who were expe-
riencing discomfort at follow-up were referred to the In the group of patients with complete follow-up there
hospital for further examination as soon as possible. were 267 women and 222 men with a mean age of 59
Stenosis was defined as stricture of the lower rectum that years. The higher incidence of stenosis in women was
cannot be passed by the finger. statistically insignificant (P = 0.32) (Table 1). Of the 489
patients 357 (73%) had no previous interventions; how-
ever, 7 of the 12 patients (58.3%) with postoperative
Statistical Methods stenosis had had a previous sclerosis injection. In con-
trast, only 95 of 477 patients (20.0%) without stenosis had
Statistical analysis was performed using the SPSS
had sclerosis injections, a difference that was statistically
12.0 software package (SPSS Inc., USA). Pearson’s chi-
significant (P = 0.02).
square test compared the incidence of variables for the
groups with and without stenosis. The actuarial compli-
cation curve was calculated and plotted according to the Procedure-related Characteristics
Kaplan-Meier life-table method. Variables with P value <
0.05 were considered to be significant. All patients underwent PPH (Table 2). The histological
examination of the resected mucosa specimen revealed
evidence of squamous skin in 53 specimens, but there was
no significant difference between two groups (P = 0.77).
RESULTS For different reasons, a second operative procedure was
carried out in 5 patients (1%), none of whom had a rectal
Rectal stenosis was observed in 12 patients (2.5%). stricture (P = 0.53). In contrast, it was remarkable that 3 of
The time to stenosis ranged from 89 to 134 days, with a the 12 patients (25%) from the stenosis group had severe
median time to stenosis of 125 days (Fig. 1). All of these postoperative pain, but only 32 of 477 patients (6.7%)
patients complained of obstructive defecation and were without stenosis experienced severe pain. This difference
found to have a stricture ring of the lower rectum that was statistically significant (P = 0.003).
Yao et al.: Rectal Stenosis after PPH Operations 1313

Table 1.
Patient characteristics
Variable Stenosis group (n = 12) No stenosis group (n = 477) P Value
Age 58.7 – 12.4 59.3 – 15.4 0.60
Gender
Male 4 (33.3%) 218 (45.7%)
Female 8 (67.7%) 259 (54.3%) 0.32
Prior treatment
None 2 (16.7%) 130 (26.6%)
Yes 10 (83.3%) 347 (72.7%) 0.07
Sclerosis therapy 7 (58.3%) 95 (20.0%) 0.02
Conventional surgery 5 (41.6%)a 252 (52.8%) 0.11
a
Three patients had both sclerosis and surgery.

Table 2.
Surgery-related details
Variable Stenosis group (n = 12) No stenosis group (n = 477) P Value
Histology
Squamous cells 2 (16.6%) 51 (10.7%)
Smooth muscle 2 (16.6%) 62 (13.0%) 0.77
Revision 472
None 12 5 0.53
One or more 0
Severe pain 3 (25%) 32 (6.7%) 0.003

DISCUSSION The data presented here showed a crude incidence of

The main complications following PPH were bleeding,
pain, inflammation, and recurrence, Rectal stricture is
rare, but it is one of the most disabling complications.8–10
Thus some basic questions concerning stenotic events
after PPH need to be discussed. First is the question is
whether the stricture can be regarded as rectal stenosis
or whether the stenosis is more likely located in the anal
canal. According to the classification for postsurgical
stenosis published by Milsom and Mazier the stenosis
would be described as high anal stenosis.11 From our
understanding, stenosis caused by PPH is presumed to
be rectal stenosis, because the causative event was
resection of the rectal mucosa. Nevertheless, although it
is theoretically regarded as rectal stenosis, the compli-
cation might appear as anal stenosis. Second, the des-
ignation of stenosis is not well defined, although some
surgeons have used an approximate description of the
term.12,13 We defined stenosis as a stricture that made it
difficult to passed a finger on rectal examination. Perhaps
more important is a definition of the stenosis according to
its symptoms. So a patient’s complaint of obstructive
defecation, together with difficulty of rectal examination,
indicate that a rectal anastomosis stenosis is present.
stenosis after PPH of 2.5%, which is comparable to the
stenosis rate published by other authors. A few studies
reported no stenotic events after PPH1,14–20; however,
the stenosis rate following stapled mucosectomy gener-
ally ranges between 0.8% and 5.0%.12,21–25 The calcu-
lated actuarial 1-year stenosis rate is 2.5%, which is
higher than the above-mentioned published stenosis
rates. In direct comparison in prospective randomized
trials there was not a significant difference in stenosis rate
between conventional hemorrhoidectomy and PPH.21,26
One mechanism that might cause a stenosis following
PPH is ring dehiscence followed by submucous inflam-
mation. Although no events of severe postsurgical infec-
tion were noted in this study, in our experience some
unrecognized transanal inflammation may cause severe
postsurgical pain, a predictive factor in our data. For pa-
tients complaining of severe postsurgical pain, oral anti-
biotics were prescribed, and this treatment relieved the
symptoms in some cases. We think that prophylactic
antibiotics in conjunction with the operation may prevent
inflammation after surgery17 and thus decrease the
postsurgical stenosis rate.
Another theoretical cause is low placement of the sta-
pled ring. If it is placed too low in the anal canal, the
1314
squamous skin cells may react by scaring and shrink-
ing.13 Although Brisinda postulated full-thickness excision
of the rectal wall another potential cause of stenosis after
PPH,27 in our study, there was no evidence to supported
this conclusion or the theoretical effect of low placement
of the stapled ring. Another predictive factor, one that is
supported by the present study, is previous sclerosis
therapy. This may have caused scarring high in the anal
canal, and the presence of scar tissue could contribute to
the stenosis rate.
Balloon dilation and strictureplasty with electrocautery
through colonscopy can be useful methods of dealing
with stenosis following PPH.9,10,28–30 In 10 of the 12 pa-
tients with stenotic stricture in our series, balloon dilation
was sufficient to relieve the stenosis. However, a small
proportion of patients will not profit from dilatation, as was
the cases in 2 of our 12 patients. Although, there is also
an option to treat these patients with medication, in
case of persisting scarring strictureplasty, treatment with
electrocautery using a linear cutter device through co-
lonscopy offers another alternative. Scar tissue can also
be resected with an ordinary circular stapling device.
CONCLUSIONS
Although, conclusions drawn from a retrospective
analysis are of limited value, especially when the follow-
up is incomplete, the data presented here provide evi-
dence that symptomatic rectal stenosis is an uncommon
event after PPH. Early stenosis will occur within the first 4
months after surgery. From the series reported here, the
follow-up of only 1 year prohibits drawing any conclusions
about late stenotic events. In most cases, the stenosis
can be treated with balloon dilation or strictureplasty with
electrocautery through colonoscopy. Two predictive fac-
tors for stenosis in the patient characteristics are previous
sclerosis therapy for hemorrhoids and severe postoper-
ative pain.
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