Does a more extensive mucosal excision prevent

haemorrhoidal recurrence after stapled

haemorrhoidopexy?
Long-term outcome of a randomized controlled trial

D. F. Altomare*, G. Pecorella†, G. Tegon‡, F. Aquilino*, D. Pennisi† and

M. De Fazio*
 INTRODUCTION

• Several randomized controlled trials and metaanalyses have

demonstrated less postoperative pain and earlier return to work after
stapled haemorrhoidopexy (SH) than Milligan–Morgan (MM)
haemorrhoidectomy.

• An inadequate quantity of mucosa resected during SH due to the

limited capacity of the case of the PPH-01/03 staplers has been
suggested to explain the greater recurrence.
 INTRODUCTION

• The aim of the present study:

To assess the longterm outcome of patients having PPH or EEA stapler
haemorrhoidopexy for Stage III haemorrhoids with symptoms of
recurrence and mucosal prolapse as endpoints.

• Patients with Stage III
haemorrhoids treatment by a
PPH-01/03 or EEA stapler
• Reviewed at a minimum follow-
up period of 36 months.
METHOD
• Recurrent prolapse:
Any degree of mucosal prolapse
occurring after defaecation or
Seen during anoscopy
Graded according to Goligher’s
classification
 METHOD
• The overall wellness evaluation (OWE) after surgery was scored by a
0–10 visual analogue score
• The severity of recurrent clinical symptoms was scored using the 0–26
point Haemorrhoid Symptom Score (HSS)
• The postoperative occurrence of any bowel dysfunction during
defaecation was assessed according to the Rome III criteria
• Rectal bleeding: low grade (small spots on the underwear after
defaecation),moderate (small spots not related to defaecation) and
severe (red blood not related to defaecation).
• Anal pain was lasting more than 1 h and graded using a VAS.
• Tenesmus
• urgency
RESULTS
RESULTS
 DISCUSSION

• Compared with MM haemorrhoidectomy, SH has the disadvantage of a higher

rate of recurrence

• Other possible reasons for an apparently higher incidence of prolapse after PPH

such as persisting constipation or straining during defaecation might be

relevant, but the finding of the study that the EEA achieves a more extensive

mucosal resection and results in significantly fewer persistent haemorrhoid

symptoms is likely to be significant.


Burch et al.
• the odds ratios for recurrent
prolapse and re-intervention for
prolapse after SH compared
with the MM operation were
4.34 and 6.78
Recent Swedish study
• Persisting haemorrhoidal
symptoms and continence
disturbance were found in the
present study in one-third of
the patients after long-term
follow-up with a rate of
recurrent prolapse of 13%
DISCUSSION
Boccasanta et al.
•STARR was proposed
to overcome the problem of
recurrent prolapse
•Resection of the rectum to cure
haemorrhoids and the high cost
of the procedure, however, make
the acceptance of STARR difficult
among proctologists.
 DISCUSSION
• The value of using a ‘high volume stapler’ (CPH34 HV; Frankenman
International Ltd, Sheung Wan, Hong Kong) to decrease the prolapse
recurrence rate was suggested

In contrast another study using the same stapler CPH34 HV failed to demonstrate
any change in the volume of mucosa resected

The main limitation of the study is the loss of onethird of the patients originally
recruited and therefore the number of patients available for the long-term follow-
up is less than the sample size determined by the power calculation
 CONCLUSION

• In conclusion, the use of a larger volume case stapler (EEA) for Stage
III haemorrhoids can provide better symptom resolution in bleeding,
better HSS and better OWE compared with the standard PPH, but it
probably does not reduce the incidence of recurrent mucosal
prolapse.
TERIMA KASIH