Circular Staplers for Hemorrhoids

7/30/2019 Circular Staplers for Hemorrhoids

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Circular Staplers for

Hemorrhoids Author: Judy Lin, MD; Chief Editor: Kurt E Roberts, MD more...

Products

Hemorrhoidopexy staplers are specialized circular staplersthat are used to resect excess prolapsed hemorrhoidal tissueand fix the rest of the hemorrhoidal tissue to the distal rectal

wall. See image below.


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Stapled hemorrhoidopexy. Image reproduced from original with

permission of the American Society of Colon & Rectal Surgeons.

Category

Staplers, circular, hemorrhoidopexy

Device detailsCovidien - EEA (end-to-end anastomosis) Hemorrhoid andProlapse Stapler Set with DST Series Technology


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Ethicon - PPH (procedure for prolapse and hemorrhoids)Hemorrhoidal Circular Stapler

Design Features

Staplers for stapled hemorrhoid surgery (hemorrhoidopexy)are based on circular anastomotic staplers. Both the Covidienand Ethicon instruments, offered in a 33-mm size, place twostaggered circular rows of titanium staples and remove acircular tissue specimen.

The Covidien stapler is offered with 3.5-mm or 4.8-mm leg-length staples; the Ethicon stapler places 4-mm staples.

The staplers are used in conjunction with a circular analdilator and a purse-string anoscope.

Indications

Hemorrhoids are swollen blood vessels in the lower rectum.

They are among the most common causes of anal pathology.The most common presentations of hemorrhoids are rectalbleeding, pain, pruritus, and prolapse.

In the United States, up to one third of the 10 million peoplewith hemorrhoids seek medical treatment, resulting in 1.5million related prescriptions per year. Hemorrhoids plague allage groups, although they occur most often in individualsaged 46-65 years.

Hemorrhoids are classified into internal and externalhemorrhoids according to their anatomic origin within the analcanal and their position relative to the dentate line.


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External hemorrhoids are located distal to the dentate line andcause pain when they thrombose. This area is covered with

sensate squamous epithelium, so the patient typically reportspain, swelling, itching, or a combination of these symptoms.

Internal hemorrhoids are located proximal to the dentate line.This area is composed of insensate columnar-glandularepithelium. Internal hemorrhoids bleed, prolapse, or both.Patients typically present with sudden painless bleeding,usually after a bowel movement. With chronic anal prolapse,patients may experience perianal itching and irritation.

Internal hemorrhoids are graded as follows:

Grade I - Prolapse below the dentate line with strain, butretract with relaxation

Grade II - Prolapse past the anal verge with strain, butreduce spontaneously

Grade III - Prolapse past the anal verge with strain and mustbe reduced manually

Grade IV - Chronic prolapse past the anal verge that is notreducible

Stapled hemorrhoid surgery, or procedure for prolapsinghemorrhoids (PPH), was first described in 1997-1998, andhas since become prominent. PPH is indicated mainly fortreating symptomatic large internal hemorrhoids with aminimal external component that are not amenable toconservative and nonoperative therapies.[1, 2]

PPH does not directly affect external hemorrhoidal tissue.Reports have described shrinking of external hemorrhoidaltissue after PPH, probably owing to decreased blood flow.


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Clinical Trial Evidence

In a Cochrane meta-analysis of randomized, controlled clinical

trials (RCTs) of PPH versus conventional excisionalhemorrhoidectomy (CH), patients who underwent PPH weresignificantly more likely to have recurrent hemorrhoids in long-term follow-up at all time points than those who underwent CH(12 trials, 955 patients; odds ratio [OR], 3.22; confidenceinterval [CI], 1.59-6.51; P= 0.001). Patients with PPH weresignificantly more likely to complain of prolapse at all timepoints (13 studies, 1191 patients; OR, 2.65; CI, 1.45-4.85; P=

0.002) and were more likely to require an additional operativeprocedure (8 papers, 553 patients; OR, 2.75; CI, 1.31-5.77, P= 0.008). A nonsignificant trend in improved pain wasassociated with PPH at all time points as compared with CH(11 studies, 823 patients; OR, 0.79; CI, 0.50-1.24; P= 0.31).Reports of serious complications with either technique werevery rare.[3]

Nisar et al performed a systematic review of 15 randomizedtrials (1077 patients) comparing PPH and CH. They found thatpatients who underwent PPH had a shorter inpatient stay(weighted mean difference [WMD], -1.02 days; 95% CI, -1.47to -0.57; P= 0.0001), shorter operative time (WMD, -12.82minutes; 95% CI, -22.61 to -3.04; P= 0.01), and earlier returnto normal activity (standardized mean difference, -4.03 days;95% CI, -6.95 to -1.10; P= 0.007). Qualitative analysisshowed PPH to be less painful than CH. However, PPH

showed a higher recurrence rate (OR, 3.64; 95% CI, 1.40-9.47; P= 0.008) at a minimum follow-up of 6 months.[4]

A systematic review by Tjandra and Chan of RCTs (1918procedures) found that PPH offered significantly shorter


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operating times (WMD, -11.35 minutes; P= 0.006), earlierreturn of bowel function (WMD, -9.91 hours; P< 0.00001),

and shorter hospital stay (WMD, -1.07 days;P

= 0.0004)compared with CH. Patients who underwent PPH experiencedless pain, as evidenced by lower pain scores at rest and ondefecation and 37.6% reduction in analgesic requirement.PPH also allowed a faster functional recovery with shortertime off work (WMD, -8.45 days; P< 0.00001) and earlierreturn to normal activities (WMD -15.85 days, P= 0.03).[5]

Burch et al performed a clinical effectiveness review that

included 27 RCTs (2279 patients: 1137 PPH, 1142 CH). PPHwas associated with less pain in the immediate postoperativeperiod; shorter operating times, hospital stay, time to firstbowel movement, and return to normal activity; but a higherrate of residual prolapse, prolapse in the longer term andreintervention for prolapse. There was no clear difference inthe rate or type of complications associated with the twotechniques. Burch et al also included a cost-effectiveness

analysis that showed the two techniques to be similaroverall.[6]

A meta-analysis by Shao et al of 29 RCTs (2056 patients)also showed PPH to be associated with decreased pain in theearly postoperative period, increased recurrence of prolapse,shorter hospital stay (WMD, -0.95 days; 95% CI, -1.32 to -0.59; P< 0.001), and reduced operating time when comparedwith CH.[7]

Clinical Implementation

In PPH, a purse-string suture is placed in the mucosal andsubmucosal layers circumferentially, approximately 3-4 cm


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above the dentate line. The hemorrhoidopexy stapler isplaced and slowly closed around the purse string. Care is

taken to draw excess internal hemorrhoidal tissue into thestapler. The stapler is fired, resecting the excess tissue andplacing a double circular staple line above the dentate line.The result is resection of excessive internal hemorrhoidaltissue, fixation of the internal hemorrhoidal tissue left behind,and interruption of the arterial blood supply from above,inducing involution of the hemorrhoidal plexus (see imagebelow)

Stapled hemorrhoidopexy. Image reproduced

from original with permission of the American Society of Colon & Rectal

Surgeons.

PPH can be performed as an outpatient procedure usinggeneral anesthesia or local anesthesia with intravenoussedation.

For detailed descriptions of stapled hemorrhoidopexy, see theeMedicine articlesHemorrhoidectomyandAnal Surgery forHemorrhoids.

Follow-up/Monitoring

Stool softeners can be used to ensure a more comfortablefirst bowel movement. Pain is usually most severe in the first72 hours after the procedure and can be alleviated with
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nonnarcotic analgesics. Pain is not exacerbated by bowelmovements.

The patient should be seen for a postoperative visit 4-6 weeksafter the procedure, as a rectal examination can be toleratedat this point.

Complications

Complications of stapled hemorrhoidopexy, although rare,may include the following:

Anovaginal fistulas Substantial hemorrhage Retroperitoneal sepsis Rectal perforation

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Circular Staplers for Hemorrhoids

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