Impact of stapled haemorrhoidopexy on stool continence and anorectal function long-term follow-up of 242 patients

Transcription

1 Langenbecks Arch Surg (2008) 393: DOI /s ORIGINAL ARTICLE Impact of stapled haemorrhoidopexy on stool continence and anorectal function long-term follow-up of 242 patients Stefan Riss & Philipp Riss & Michael Schuster & Thomas Riss Received: 10 July 2007 / Accepted: 5 December 2007 / Published online: 3 January 2008 # Springer-Verlag 2007 Abstract Background and aims Several studies have proved the feasibility and safety of stapled anopexy for treating haemorrhoidal prolapse. However, stool urgency and faecal incontinence as possible side effects are still debated. Therefore, the present study was designed to assess the impact of Longo s procedure on stool continence and anorectal function. Materials and methods From 1999 to 2005, 300 patients underwent stapled haemorrhoidopexy for symptomatic haemorrhoidal prolapse. Two hundred forty-two patients (100 women, 142 men) were available for follow-up and were retrospectively reviewed. All operations were performed by one single surgeon. To evaluate anorectal function, the results of a validated incontinence score (total incontinence score [IS]: 0 = best, 20 = worst) and evacuation score (total evacuation score [ES]: 0 = worst, 28 = best) were compared pre- and postoperatively. Results The total IS showed no difference in means before and after operation (p=0.875, CI 95%) retrospectively. Concerning the ES, paired sample t-test showed a weak positive correlation, indicating a significant difference in score means (p=0.041, CI 95%). The group means changed from before operation to after the follow-up period. S. Riss : P. Riss : M. Schuster : T. Riss Department of General Surgery, Hartmannspital, Nikolsdorfergasse 26-36, 1050 Vienna, Austria S. Riss (*) Department of Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria stefan.riss@meduniwien.ac.at Conclusion The present data revealed no significant negative impact of Longo s technique on anorectal function. In contrast, according to the evacuation score, the results showed a significant improvement of evacuation. Keywords Haemorrhoids. Stapled anopexy. Stapled haemorrhoidopexy. Incontinence. Surgery Introduction In the year 1998, A. Longo presented a new operation technique for treating symptomatic haemorrhoidal prolapse [1]. This technique is based on a new theory of aetiology and treatment of haemorrhoids. In this concept, the haemorrhoidal prolapse is always associated with an internal rectal prolapse. By resecting a mucosal doughnut of the distal rectum, the internal prolapse is reduced and the haemorrhoidal plexus is lifted up in a physiological position. Several studies compared conventional surgery techniques with stapled anopexy. Low postoperative pain and the early return to work were regarded as great advantages over conventional methods [2 6]. Since Cheetham et al. reported about persisted faecal urgency after Longo s procedure, concern arose whether this technique may affect patients continence [7]. In the following years, only a small number of studies focussed on the postoperative functional outcome. Few randomised control trials used incontinence scores and found no difference between Milligan Morgan s operation (MM) and Longo s procedure [8, 9]. Anyway, those studies included small patients sample and had a short follow-up. Because of a lack of functional results after a long-time period, the present study was designed to assess the impact

2 502 Langenbecks Arch Surg (2008) 393: of Longo s procedure on stool continence and anorectal function. Materials and methods From 1999 to 2005, 300 patients underwent stapled haemorrhoidopexy for symptomatic haemorrhoidal prolapse. Two hundred forty-two patients (100 women, 142 men) were available for follow-up and were included in this study. The other patients could not be contacted either by telephone or by mail. Mean age was 59 years (range years) with a mean follow-up time of 48 months (range 7 92 months). During this time period, stapled haemorrhoidopexy was the only surgical technique that was offered to our patients suffering from symptomatic haemorrhoidal prolapse. Inclusion criteria were symptomatic haemorrhoidal piles after conservative treatment failure. Patients with acute haemorrhoidal episodes with thrombosis, irreducible haemorrhoidal piles and intercurrent anal pathologies (i.e. fissure, fistula, anal incontinence not due to haemorrhoids disease) were excluded. Patients with haemorrhoidal piles grade II were only chosen for operation, if conservative treatment failed to achieve symptom control. All operations were performed by one single surgeon. Haemorrhoidal degree was staged as degree II in 20.2%, degree III in 76% and degree IV in 3.8% of the patients. Patients were questioned personally by an independent investigator about their anorectal function before and after operation retrospectively. To evaluate anorectal function, a validated incontinence score (total incontinence score [IS]: 0 = best, 24 = worst) and evacuation score (total evacuation score [ES]: 0 = worst, 28 = best) were used and compared pre- and postoperatively (Tables 1 and 2) [10, 11]. Additionally, we used a standardised questionnaire to evaluate clinical symptoms and reprolapse rate. Anal anatomy was assessed by clinical examination. The height of the purse suit suture was measured by digital examination. All data were collected and statistically analysed using SPSS ( Chicago, USA). Operation technique The operation is performed in lithotomy position. The anus is gently dilated by using the obturator. Perianal traction sutures are inserted at 3, 6, 9 and 12 o clock to fix the circular anal dilatator (Ethicon CAD 33). The traction sutures must not catch prolapsed tissue, to enable the complete repositioning of the prolapsed piles. By means of a special side open anoscope (Ethicon PSA 33), a purse string suture is inserted into the mucous membrane of the distal rectum, about 2 3 cm above the haemorrhoidal tissue. Using a circular stapler device (Ethicon PPH 01), a mucosal doughnut is resected. The resulting stapler line is situated approximately 2 cm above the dentate line. Thus, the rectal venous plexus is not excised but lifted into the proximal anal canal. Bleeding around the stapler line is controlled by absorbable sutures or by using diathermy. The excised mucosal doughnut is measured and sent to histological examination. Results Early postoperative complications included urinary retention (n=8, 3.3%), bleeding (n=3, 1.2%) and anal stenosis (n=2, 0.8%). Patients with anal stenosis could be dilated successfully. Those patients with postoperative bleeding required reoperation. Five patients (2.1%) showed recurrent haemorrhoidal prolapse and were operated with a MM procedure. Residual skin tags were observed in 26.9% (n=65) of the cases. Thirty-seven patients (15.3%) showed recurrent haemorrhoidal symptoms, including bleeding (7.9%, n=19), pain (3.3%, n=8) and itching (4.1%, n=10). There was no correlation between preoperative haemorrhoidal stage and postoperative outcome. Table 1 Questionnaire and score for evacuation (seven items, 0 28) Score No. of bowel movement/day Sensation of incomplete evacuation Never Often Sometimes Rarely Always 3 Necessity to return to bathroom <15 min Never Often Sometimes Rarely Always 4 Ability to evacuate completely <15 min Always Rarely Sometimes Often Never 5 Ability to defer evacuation >15 min Always Rarely Sometimes Often Never 6 Use of laxatives and/or enemas Never Often Sometimes Rarely always 7 Use of medications for retarding transit Never Often Sometimes Rarely Always

3 Langenbecks Arch Surg (2008) 393: Table 2 Questionnaire and score for incontinence (seven items, 0 24) Score Never Rarely Sometimes Weekly Daily 1 Incontinence for solid stool Incontinence for liquid stool Incontinence for gas Alteration in lifestyle No Yes 5 Need to wear a pad or plug Taking constipating medicines Lack of ability to defer defaecation for 15 min 0 4 Add one score from each row: minimum score = 0 (perfect continence); maximum score = 24 (totally incontinent) Never No episodes in the past 4 weeks, Rarely 1 episode in the past 4 weeks, Sometimes >1 episode in the past 4 weeks but <1 a week, Weekly 1 or more episodes a week but <1 a day, Daily 1 or more episodes a day Concerning the ES, with a total range of 0 to 28, where a higher score indicates lower grade of symptoms, the group means changed from before operation to after the follow-up period. Paired sample t-test showed a weak positive correlation, indicating a significant difference in score means (p=0.041, CI 95%). The mean difference of score pre/post improved by 1.0 (SD±4.45). A factor analysis showed that 53% of the variance in the postoperative score level could be explained through the factors number of bowel movements per day and sensation of incomplete evacuation/incomplete defaecation. According to the ES, the condition of patients improved significantly. The IS with a total range of 0 to 24, where a lower score indicates a lower grade of symptoms, changed from a mean of 0.86 preoperatively to a mean of 0.84 postoperatively. The mean difference of score pre/post improved by 0.1 (SD±5.14). Paired sample t-test showed no significant difference in score means (p=0.875, CI 95%). A factor analysis showed that 68% of the variance in the postoperative score level could be explained through the factors incontinence for solid stool, incontinence for liquid stool and incontinence for gas. According to the IS, there is no significant difference in means. We separated the results of the IS and ES for men and women and found no gender-specific effects. The score means of both groups were in line with the general results. Moreover, we performed a paired sampled t-test for women aged over 55 years (n=63). The result of the ES changed from a mean of before operation to after the follow-up period, indicating a non-significant, positive correlation (p=0.134, mean difference: 0.63, SD±3.318). The IS changed from a mean of 1.13 preoperatively to 0.90, representing a non-significant correlation (p=0.519, mean difference 0.22, SD±2.721). The height of the purse suit suture could be measured in 66 cases (30 women, 36 men), with a mean height of 4.45 cm (SD±0.8). There was no suture detectable in the remaining patients. The existing data indicated a negative correlation between the height of the purse suit suture and the postoperative IS (Kendalls tau b, p= 0.015, CI 95%). Discussion A. Longo postulates a redundant rectal mucosa as primary alteration for the pathogenesis of haemorrhoidal disease. This internal mucosal prolapse is regarded as a barrier causing difficulties for the passage of faeces. By a descensus and expulsion of the haemorrhoidal tissue, the redundant mucosa is stretched whereby the rectal lumen is freed and defaecation enabled. In fact, it can be demonstrated intraoperatively that the anal canal is covered by rectal mucosa, when the haemorrhoidal tissue is expelled. Pushing back the haemorrhoids and introducing the CAD, the internal rectal redundancy is visible. As a consequence of the pathogenetic concept, stapled anopexy removes the internal rectal prolapse and does not resect the prolapsed haemorrhoidal tissue, which is rather lifted and fixed in a physiological position. In the last years, several studies compared conventional techniques with stapled anopexy with conflicting results in terms of recurrent prolapse and definitive resolution of haemorrhoidal symptoms [9, 12 15]. Few studies investigated the functional outcome after Longo s operation. Only a small number of them used validated scoring systems. Cheetham et al. reported about faecal urgency which persisted up to 15 months after operation [7]. Altomare et al. included a continence grading system in their randomised controlled study [16]. In the early postoperative period, the symptom of minor incontinence (faecal urgency) was observed in seven cases (2.9%) of the group. Six months later, only one of these patients complained about the sensation of stool urgency, but had no episodes of faecal

4 504 Langenbecks Arch Surg (2008) 393: incontinence. This patient received biofeedback training and was treated successfully. Three further studies used continence scores as well and found no significant difference compared to conventional techniques [8, 9, 15]. Ganio et al. showed a slight difference of the IS in favour of stapled anopexy [17]. However, all of these studies had a short follow-up time and included a small number of patients, thus reducing a clear statement. In the present study, we used two accepted questionnaires to assess the functional anorectal outcome. Concerning the IS, the current investigation revealed no change after operation. These results correspond with observations in literature mentioned above. One bias of the current study might be the fact that patients were questioned retrospectively about their preoperative symptoms. We tried to reduce this weakness by reviewing the clinical records of all patients, in which most variables were documented. Moreover, during the interview, none of the patients had difficulties to remember their preoperative anorectal function. In fact, although statistically not relevant, a small number of patients (n=11, 4.5%) reported about a new onset of stool urgency, which persisted over the follow-up period. This symptom need not influence patient s daily activity or satisfaction, but was definitely directly related to stapled anopexy. The reason for long-term urgency remains unclear. In the literature, it is discussed whether urgency is caused by sphincter injury due to excessive anal stretching or by incorporation of rectal muscle layer into the resected doughnut [7, 8]. A reasonable explanation might be the altered anatomy in the anal rectum, due to the lifted mucosal tissue, causing a decreased threshold for the stimulus of defaecation [12]. Ho et al. reported about internal sphincter fragmentation assessed by endoanal ultrasonography after stapled anopexy in asymptomatic patients with an incontinence score in the normal range [8]. In another study, patients underwent anal manometry and three-dimensional ultrasonography before and after operation [16]. Notably, no sphincter damage was found. Further investigations evaluated sphincter function by anal manometry as well, demonstrating no significant decrease in mean resting pressure after stapled anopexy [18 20]. As the pursuit suture is placed above the dental line and above the upper edge of the internal sphincter muscle, a direct damage of the muscle must be regarded as a severe technical mistake. Johannsson et al. reported about longterm results after MM procedure. One hundred thirty-nine patients (33%) complained about impaired anal continence in their group [21]. In 40 of the 139 patients (29%), the incontinence was a direct result of the haemorrhoidectomy. Performing excision haemorrhoidectomy, it is possible to injure directly the internal sphincter muscle causing symptoms of incontinence. We also addressed the question whether a low pursuit suture may affect patient s anorectal function. Therefore, all patients were investigated by digital examination. Interestingly, the height of the suture seemed not to correlate with urgency symptoms but indicated a negative correlation with the postoperative IS. One patient showed an incontinence score of 16 points after operation. It was the only case, in which the pursue string suture was located 2 cm above the anocutan line, thus touching the sensible anoderm. Furthermore, we found a significant impact of Longo s procedure on the ES. This observation is corresponding with Longo s concept of the origin of haemorrhoidal prolapses. As an internal rectal redundancy is regarded as the main reason for the haemorrhoidal disease, one would expect a low score before operation. Indeed, we found a significant increase of the total evacuation score after operation. Anyway, as few studies reported about a positive association between haemorrhoids and constipation, others could not detect any correlation [22 24]. Conclusion Being aware of the fact that 58 patients (20%) were missing for follow-up, the present data revealed no significant negative impact of Longo s technique on anorectal function. In contrast, the incontinence score showed a slight improvement without a statistical significance. According to the evacuation score, the results showed a significant improvement of evacuation. Acknowledgement We are grateful to Prof. F. Herbst, Medical University of Vienna, for practical help in performing this work. References 1. Longo A (1998) Treatment of haemorrhoids disease by reduction of mucosa and hemorrhoidal prolaps with circular suturing device: a new procedure. World Congress of Endoscopic Surgery, Rome, Italy 2. Hetzer FH, Demartines N, Handschin AE, Clavien PA (2002) Stapled vs excision hemorrhoidectomy: long-term results of a prospective randomized trial. Arch Surg 137(3): Kairaluoma M, Nuorva K, Kellokumpu I (2003) Day-case stapled (circular) vs. diathermy hemorrhoidectomy: a randomized, controlled trial evaluating surgical and functional outcome. Dis Colon Rectum 46(1): Mehigan BJ, Monson JR, Hartley JE (2000) Stapling procedure for haemorrhoids versus Milligan-Morgan haemorrhoidectomy: randomised controlled trial. Lancet 355(9206): Rowsell M, Bello M, Hemingway DM (2000) Circumferential mucosectomy (stapled haemorrhoidectomy) versus conventional haemorrhoidectomy: randomised controlled trial. Lancet 355 (9206): Senagore AJ, Singer M, Abcarian H, Fleshman J, Corman M, Wexner S et al (2004) A prospective, randomized, controlled

5 Langenbecks Arch Surg (2008) 393: multicenter trial comparing stapled hemorrhoidopexy and Ferguson hemorrhoidectomy: perioperative and one-year results. Dis Colon Rectum 47(11): Cheetham MJ, Mortensen NJ, Nystrom PO, Kamm MA, Phillips RK (2000) Persistent pain and faecal urgency after stapled haemorrhoidectomy. Lancet 356(9231): Ho YH, Seow-Choen F, Tsang C, Eu KW (2001) Randomized trial assessing anal sphincter injuries after stapled haemorrhoidectomy. Br J Surg 88(11): Smyth EF, Baker RP, Wilken BJ, Hartley JE, White TJ, Monson JR (2003) Stapled versus excision haemorrhoidectomy: long-term follow up of a randomised controlled trial. Lancet 361 (9367): da Silva GM, Kaiser R, Borjesson L, Colqhoun P, Lobo C, Khandwala F et al (2004) The effect of diverticular disease on the colonic J pouch. Colorectal Dis 6(3): Vaizey CJ, Carapeti E, Cahill JA, Kamm MA (1999) Prospective comparison of faecal incontinence grading systems. Gut 44(1): 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): Nisar PJ, Acheson AG, Neal KR, Scholefield JH (2004) Stapled hemorrhoidopexy compared with conventional hemorrhoidectomy: systematic review of randomized, controlled trials. Dis Colon Rectum 47(11): Ortiz H, Marzo J, Armendariz P, De Miguel M (2005) Stapled hemorrhoidopexy vs. diathermy excision for fourth-degree hemorrhoids: a randomized, clinical trial and review of the literature. Dis Colon Rectum 48(4): Racalbuto A, Aliotta I, Corsaro G, Lanteri R, Di Cataldo A, Licata A (2004) Hemorrhoidal stapler prolapsectomy vs. Milligan- Morgan hemorrhoidectomy: a long-term randomized trial. Int J Colorectal Dis 19(3): Altomare DF, Rinaldi M, Sallustio PL, Martino P, De Fazio M, Memeo V (2001) Long-term effects of stapled haemorrhoidectomy on internal anal function and sensitivity. Br J Surg 88 (11): Ganio E, Altomare DF, Gabrielli F, Milito G, Canuti S (2001) Prospective randomized multicentre trial comparing stapled with open haemorrhoidectomy. Br J Surg 88(5): Boccasanta P, Capretti PG, Venturi M, Cioffi U, De Simone M, Salamina G et al (2001) Randomised controlled trial between stapled circumferential mucosectomy and conventional circular hemorrhoidectomy in advanced hemorrhoids with external mucosal prolapse. Am J Surg 182(1): Ho YH, Cheong WK, Tsang C, Ho J, Eu KW, Tang CL et al (2000) Stapled hemorrhoidectomy cost and effectiveness. Randomized, controlled trial including incontinence scoring, anorectal manometry, and endoanal ultrasound assessments at up to three months. Dis Colon Rectum 43(12): Wilson MS, Pope V, Doran HE, Fearn SJ, Brough WA (2002) Objective comparison of stapled anopexy and open hemorrhoidectomy: a randomized, controlled trial. Dis Colon Rectum 45 (11): Johannsson HO, Graf W, Pahlman L (2002) Long-term results of haemorrhoidectomy. Eur J Surg 168(8 9): Hansen HH (1977) [New aspects of the pathogenesis and treatment of haemorrhoids (author s transl)]. Dtsch Med Wochenschr 102 (35): Hyams L, Philpot J (1970) An epidemiological investigation of hemorrhoids. Am J Proctol 21(3): Johanson JF, Sonnenberg A (1994) Constipation is not a risk factor for hemorrhoids: a case control study of potential etiological agents. Am J Gastroenterol 89(11):