Analysis of recurrence after stapled hemorrhoidopexy in grade IV hemorrhoid disease

Abstract

BACKGROUND

Stapled hemorrhoidopexy (SH) is one of the most commonly used surgical techniques for hemorrhoidal disease, being particularly effective for grade III and IV hemorrhoids. The procedure is associated with better short-term outcomes, including less postoperative pain, shorter operative time, faster return to work, and higher patient satisfaction. However, there is a risk-benefit debate surrounding SH due to significant complications from the procedure, such as anal stenosis, rectovaginal fistula, fecal incontinence, and recurrence.

AIM

To evaluate recurrence rates and factors influencing surgical outcomes following SH in patients with grade III and IV hemorrhoids.

METHODS

This retrospective, single-center study enrolled a total of 77 patients with grade III/IV hemorrhoids for analysis. Early (less than 7 days after SH) and late (7 or more days after SH) complications were analyzed. Recurrence rates were calculated as well.

RESULTS

Patients were categorized by hemorrhoid grade and showed no differences in demographic data between the two groups. Recurrence was observed in 4 patients (23.6%) with grade IV hemorrhoids, and no recurrence was noted in patients with grade III hemorrhoids. Postoperative bleeding, incomplete defecation, urgent defecation, incontinence, skin tags, and anal fissure were complications reported by both groups.

CONCLUSION

Due to the high recurrence rate, SH is not an appropriate treatment option for patients with grade IV hemorrhoids. Open surgery may be a more suitable option for these patients.

Key Words: Hemorrhoids; Stapled hemorrhoidopexy; Procedure for prolapsed hemorrhoids; Surgery; Recurrence

Core Tip: Stapled hemorrhoidopexy (SH) is widely used to treat grade III and IV hemorrhoids. While it offers advantages such as reduced postoperative pain and faster recovery, its effectiveness for advanced hemorrhoidal disease remains controversial. In this retrospective, single-center study, we analyzed the clinical outcomes of 77 patients who underwent SH. We focused particularly on recurrence rates after SH. Our observations suggest that SH is an inappropriate treatment for grade IV hemorrhoids due to a significantly higher recurrence rate.

INTRODUCTION

Hemorrhoidal disease is a common anorectal disorder with a widely varying prevalence, from 4%-45%[1]. Hemorrhoids are graded according to the Goligher classification as follows: (1) Grade I hemorrhoids, presenting with bleeding and no prolapse; (2) Grade II hemorrhoids, which will prolapse during straining but reduce spontaneously; (3) Grade III hemorrhoids, which will prolapse with straining and require manual reduction; and (4) Grade IV hemorrhoids, which remain prolapsed[2].

Grade III and IV hemorrhoids are primarily treated with surgery. The Milligan-Morgan technique, introduced in 1937, has remained the most widely performed hemorrhoidectomy procedure[3,4]. Stapled hemorrhoidopexy (SH) developed much later, in 1995[5], gained popularity due to its minimally invasive nature and favorable short-term outcomes, including reduced postoperative pain, shorter operative time, faster recovery, and higher patient satisfaction[6]. Despite these advantages, patients with higher grades of hemorrhoids who undergo SH are at a higher risk of complications, including anal stenosis, defecation difficulties, bleeding, rectovaginal fistula, recurrence, and incontinence. We designed this study to evaluate recurrence rates following SH among patients with grade III/IV hemorrhoids to identify factors that influence surgical outcome.

MATERIALS AND METHODS

Study design and ethical consideration

This retrospective study was conducted at the Health Sciences University, Ümraniye Training and Research Hospital. The study received Ethical Committee approval and all patients had signed informed consent prior to having undergone the SH procedure. The study adhered to the ethical principles of the Helsinki Declaration, ensuring patient confidentiality and the protection of personal health information.

Patient selection

Inclusion criteria: (1) Diagnosis of grade III or grade IV hemorrhoids between November 2014 and December 2019; (2) Adult patients, between the ages of 18 years and 80 years; (3) American Society of Anesthesiologists score of less than 4; and (4) Provision of informed consent for the SH procedure.

Exclusion criteria: (1) Presence of coagulation disorders; (2) Current anticoagulant therapy; (3) Inflammatory bowel disease; (4) Acute thrombosed hemorrhoids; (5) Liver cirrhosis; or (6) Pregnancy. Ultimately, a total of 77 patients fit the criteria for study enrollment.

Data collection and follow-up

Demographic, preoperative, and postoperative clinical variables were retrieved retrospectively from the hospital’s patient database. All procedures had been performed by a single specialist surgeon (Yıldız A), providing consistency in the surgical technique applied. All patients had completed the recommended follow-up, and there were no dropouts. Postoperative complications were categorized as early (occurring within 7 days after surgery) and late (occurring more than 7 days after surgery).

Operative technique

All patients had completed routine bowel preparation before their surgery. The surgical procedure itself was performed on the patient in the lithotomy position under general or spinal anesthesia, using a hemorrhoidopexy set (Ethicon Endo-Surgery; Johnson & Johnson, OH, United States).

The SH procedure was performed as follows. First prophylactic single-dose antibiotics were administered. A lubricated circular anal dilator was inserted to dilate the anus. Four 2/0 silk sutures were placed at the 3 o’clock, 6 o’clock, 9 o’clock, and 12 o’clock positions on the anoderm line to secure the obturator. A 2/0 polypropylene purse-string suture (with a 25 mm curved needle) was applied 3-4 cm above the dentate line on the mucosa and submucosa; this ensured that the excision line would remain approximately 2 cm from the dentate line. Then, the anoscope was removed, and a stapler anvil was placed beyond the purse-string suture loop. If bleeding occurred, hemostatic sutures (with 3/0 Vicryl) were applied. The stapler was fully closed and fired after 20 seconds. The procedure was completed by placing a hemostatic sponge in the anal canal. The excised specimen was sent for histopathological examination, whereby the donut specimen was checked for circularity and muscle fibers to confirm proper tissue excision.

Outcomes and follow-up

Patients underwent two postoperative evaluations, on day 10 and day 30 after surgery, managed by the same specialist surgeon. The primary outcome assessed was recurrence of the prolapse after SH. The secondary outcomes assessed were incidence of fecal urgency, incontinence, and complications.

Statistical analysis

Data analysis was conducted using SPSS 25.0 statistical software (IBM Corp., Armonk, NY, United States). The Kolmogorov-Smirnov test was applied to assess normality of the data distribution. Descriptive statistics, including mean ± SD for continuous variables and frequencies and percentages for categorical variables, were conducted. The χ² or Fisher’s exact tests were used to compare categorical data. A P value < 0.05 was considered statistically significant.

RESULTS

Patient demographics

The demographic and clinical characteristics of the patients included in this study are presented in Table 1. Antibiotic prophylaxis had been administered to all patients before surgery. All patients had been diagnosed with either grade III (78.0%) or grade IV hemorrhoids (22.0%). A total of 5 patients (6.4%) had a preoperative diagnosis of recurrent hemorrhoids, for which the SH was performed. Among them, 4 of the patients had grade III hemorrhoids and 1 patient had grade IV hemorrhoids; these patients had all previously undergone open hemorrhoidectomy.

Table 1 Demographic and clinical characteristics of the patients, n (%).

Characteristic	Grade III, n = 60	Grade IV, n = 17
Sex
Male	42 (70.0)	12 (70.6)
Female	18 (30.0)	5 (29.4)
ASA score
1	53 (88.3)	15 (88.2)
2	5 (8.3)	2 (11.7)
3	2 (3.3)	NA
Preoperative recurrence	4 (6.7)	1 (5.9)
Preoperative bleeding	17 (28.3)	8 (47.0)
Preoperative bleeding requiring transfusion	4 (6.7)	2 (11.8)
Postoperative recurrence	NA	4 (23.6)
Postoperative early bleeding	2 (3.3)	NA
Postoperative late bleeding	7 (11.7)	3 (17.7)
Postoperative bleeding requiring transfusion	2 (3.3)	2 (11.8)
Incomplete defecation	11 (18.3)	5 (29.4)
Urgent defecation	4 (6.7)	3 (17.7)
Incontinence/soiling	7 (11.7)	5 (29.4)
Residual skin tags	17 (28.3)	8 (47.0)
Anal fissure	3 (5.0)	NA
Reoperation	2 (3.3)	3 (17.7)

ASA: American Society of Anesthesiologists; NA: Not available.

Early complications

Early postoperative bleeding, within the first 7 days after the SH, occurred in 2 patients (3.3%) with grade III hemorrhoids and no patients with grade IV hemorrhoids. Late postoperative bleeding, more than 7 days after the SH, occurred in 7 patients (11.7%) with grade III hemorrhoids and 3 patients (17.7%) with grade IV hemorrhoids. Blood transfusion was required for 2 patients (3.3%) with grade III hemorrhoids and 2 patients (11.8%) with grade IV hemorrhoids, prompted by bleeding events. Severe postoperative bleeding occurred in 2 patients (2.8%) with grade IV hemorrhoids. In one of those patients the bleeding occurred on the first postoperative day, and for the second it occurred at 10 days after the SH. Examination under general anesthesia showed no active bleeding at the anastomosis line for both. As part of the treatment, two units of erythrocyte suspension and one unit of fresh frozen plasma were administered.

Postoperatively, patients were asked to report voiding complications. Among the total study population, 20.8% of the patients reported the experience of a sensation of incomplete evacuation after defecation. In addition 15.6% of patients reported incontinence and 9.1% reported experiencing urgency in defecation. For all, the symptoms were reported as significantly decreasing within 3 months postoperatively but not completely disappearing. When rectosigmoidoscopy was performed on the patients with these complications, only scar tissue was observed.

Recurrence

Recurrence occurred in 4 patients (23.6%) with grade IV hemorrhoids, detected at 8 months and 12 months after the SH. Recurrence was not observed in any of the patients with grade III hemorrhoids. One of the recurrence patients underwent reoperation at 8 months after the SH, via open surgery performed using the Ferguson technique. Another patient refused surgery and received conservative treatment with a follow-up plan; the patient was informed that the likelihood of reoperation in the future was high.

DISCUSSION

Anorectal diseases, which include hemorrhoids, are among the most prevalent conditions affecting the adult population. Hemorrhoidal disease affects one in three adults, with approximately 10%-20% of cases requiring surgical intervention[7]. Development of hemorrhoidal disease is believed to involve pathological changes in the anal cushions, which are essential structures in the subepithelial space of the anal canal composed of connective tissue and smooth muscle fibers within a fibroelastic network. According to Cheetham and Phillips[8] the postoperative complications of perianal pain and urgency are related to smooth muscle fibers present in the surgically excised tissue. In addition, muscle fiber presence in the resected tissue is also noted as a risk factor for postoperative development of strictures and incontinence, as are high-grade hemorrhoids and residual sphincter hypertonia.

Although SH is commonly utilized for the treatment of grade III/IV hemorrhoids, we would argue that its effectiveness in treating grade IV hemorrhoids is debatable because of the high recurrence rates observed in this group of patients. The SH procedure is based in fixation of the excised hemorrhoidal mucosa to the distal rectal wall[8]. Among its beneficial results are lower postoperative pain, quicker return to daily activities, and higher patient satisfaction when compared with conventional hemorrhoidectomy[9]. According to Shao et al[9], SH also has shorter operative times, reduced postoperative pain, and faster recovery than traditional surgical methods including surgical hemorrhoidectomy. However, those authors also reported overall complication rates being similar between the various techniques evaluated and, notably, that SH had a higher recurrence rate. Similarly, Thaha et al[10] found that patients treated with SH had significantly less postoperative pain and higher satisfaction than their counterparts treated with closed diathermy hemorrhoidectomy, but the recurrence rate at the 1-year follow-up was notably higher for the former. Several studies have also reported that patients with grade IV hemorrhoids, in particular, are more likely to experience recurrent prolapsed hemorrhoids[11,12].

In our study, we observed a lower postoperative recurrence rate for patients with grade III hemorrhoids compared to patients with grade IV hemorrhoids; the latter developed recurrences within 1 year of the SH treatment. In general, recurrences may be related to incomplete mucosal resection due to the excessive volume of prolapsed hemorrhoidal tissue. A meta-analysis by Giordano et al[13] found recurrence rates of 22.0% after SH treatment and 3.6% following traditional hemorrhoidectomy for grade IV hemorrhoids. Another study found a recurrence rate as high as 58.9% after SH but the median recurrence rate was determined to be substantially lower, at 6.9%[13].

Late complications occur more than 7 days postoperatively. Reported complication rates related to SH range from 2.5% to 80.0%, with a median of 23.7%[12]. Early postoperative bleeding is a common complication following hemorrhoid surgery and is often a result of insufficient intraoperative hemostasis in the early period. However, late bleeding is typically caused by constipation and tenesmus, with a reported rate range of 4%-25%[14]. The postoperative complication of tenesmus is reported more frequently for SH than for other hemorrhoidectomy techniques, with reported rates ranging from 0% to 40%[15]. In our study postoperative bleeding occurred in 9.7% of the patients, consistent with previous findings[16].

Another common complication of SH is urgent defecation. This symptom is typically transient but its persistence has been reported in 2.9% of patients up to 2 years after the surgery[15]. In our study, 5.6% of patients reported urgency after undergoing the SH procedure. This rate is similar to that of early fecal urgency and soiling rates, with reported rates ranging from 0.2% to 25.0% and a median of 8.3%[16]. Fecal incontinence and soiling are commonly experienced as late complications but can occur in the early postoperative period as well. In our study incontinence/soiling was observed in 2.7% of the patients. Other common complaints included anal fissures and skin tags, with the latter being generally more common after SH than after other hemorrhoidectomy methods. We observed skin tags in 18.5% of our patients, which aligns with other reports[17,18].

One of the distinctive strengths of our study was that all of the SH operations assessed had been performed and managed by a single specialist surgeon. This ensured consistency in the surgical technique and postoperative care. However, this inherently led to a relatively small sample size. Along with the retrospective nature of the study design, these were the main limitations of this study.

CONCLUSION

SH is a safe technique that offers patients low postoperative pain and early recovery. However, we found a high recurrence rate among SH-treated patients with grade IV hemorrhoids. Meticulous preoperative patient selection and application of proper surgical technique are of the utmost importance for achieving optimal outcomes. While recurrence was observed in patients with grade IV hemorrhoids, we did not observe any recurrence among SH-treated patients with grade III hemorrhoids. Therefore, while we consider SH an ideal method for the treatment of grade III hemorrhoids, we recommend open surgery for grade IV cases to achieve lower recurrence rates and improved long-term outcomes.