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Meta-Analysis
. 2006 Oct 18;2006(4):CD005393.
doi: 10.1002/14651858.CD005393.pub2.

Stapled versus conventional surgery for hemorrhoids

K J Lumb #, P H D Colquhoun, R A Malthaner, S Jayaraman  1
Affiliations
Meta-Analysis

Stapled versus conventional surgery for hemorrhoids

K J Lumb et al. Cochrane Database Syst Rev. .

Abstract

Background: Hemorrhoids are one of the most common anorectal disorders. The Milligan‐Morgan open hemorrhoidectomy is the most widely practiced surgical technique used for the management of hemorrhoids and is considered the current "gold standard". Circular stapled hemorrhoidopexy was first described by Longo in 1998 as alternative to conventional excisional hemorrhoidectomy. Early, small randomized‐controlled trials comparing stapled hemorrhoidopexy with traditional excisional surgery have shown it to be less painful and that it is associated with quicker recovery. The reports also suggest a better patient acceptance and a higher compliance with day‐case procedures potentially making it more economical. A previous Cochrane Review of stapled hemorrhoidopexy and conventional excisional surgery has shown that the stapled technique is associated with a higher risk of recurrent hemorrhoids and some symptoms in long term follow‐up. Since this initial review, several more randomized controlled trials have been published that may shed more light on the differences between the novel stapled approach and conventional excisional techniques.

Objectives: This review compares the use of circular stapling devices and conventional excisional techniques in the surgical treatment of hemorrhoids. Its goal is to ascertain whether there is any difference in the outcomes of the two techniques in patients with symptomatic hemorrhoids.

Search strategy: We searched all the major electronic databases (MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) from 1998 to December 2009.

Selection criteria: All randomized controlled trials comparing stapled hemorrhoidopexy to conventional excisional hemorrhoidal surgeries with a minimum follow‐up period of 6 months were included.

Data collection and analysis: Data were collected on a data sheet. When appropriate, an Odds Ratio was generated using a random effects model.

Main results: Patients with SH were significantly more likely to have recurrent hemorrhoids in long term follow up at all time points than those with CH (12 trials, 955 patients, OR 3.22, CI 1.59‐6.51, p=0.001). There were 37 recurrences out of 479 patients in the stapled group versus only 9 out of 476 patients in the conventional group. Similarly, in trials where there was follow up of one year or more, SH was associated with a greater proportion of patients with hemorrhoid recurrence (5 trials, 417 patients, OR 3.60, CI 1.24‐10.49, p=0.02). Furthermore, a significantly higher proportion of patients with SH complained of the symptom of prolapse at all time points (13 studies, 1191 patients, OR 2.65, CI 1.45‐4.85, p=0.002). In studies with follow up of greater than one year, the same significant outcome was found (7 studies, 668 patients, OR 3.14, CI 1.20‐8.22, p=0.02). Patients undergoing SH were more likely to require an additional operative procedure compared to those who underwent CH (8 papers, 553 patients, OR 2.75, CI 1.31‐5.77, p=0.008). When all symptoms were considered, patients undergoing CH surgery were more likely to be asymptomatic (12 trials, 1097 patients, OR 0.59, CI 0.40‐0.88). Non significant trends in favor of SH were seen in pain, pruritis ani, and fecal urgency. All other clinical parameters showed trends favoring CH.

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Conflict of interest statement

None

Figures

1.1
1.1. Analysis
Comparison 1 Asymptomatic patients, Outcome 1 patients with no hemorrhoidal symptoms.
1.2
1.2. Analysis
Comparison 1 Asymptomatic patients, Outcome 2 patients with no hemorrhoidal symptoms at follow up >1year but <2 years.
2.1
2.1. Analysis
Comparison 2 Bleeding, Outcome 1 number of patients with bleeding consistent with hemorrhoids.
2.2
2.2. Analysis
Comparison 2 Bleeding, Outcome 2 Proportion of patients experiencing bleeding consistent with hemorrhoidal bleeding at final follow‐up.
2.3
2.3. Analysis
Comparison 2 Bleeding, Outcome 3 Patients with bleeding at follow up >1 year but <2 years.
2.4
2.4. Analysis
Comparison 2 Bleeding, Outcome 4 patients with bleeding at follow‐up >2years.
3.1
3.1. Analysis
Comparison 3 Prolapse, Outcome 1 Proportion of patients complaining of hemorrhoidal prolapse at final follow‐up.
3.2
3.2. Analysis
Comparison 3 Prolapse, Outcome 2 patients complaining of prolapse at follow‐up >1 year but <2 years.
3.3
3.3. Analysis
Comparison 3 Prolapse, Outcome 3 patients complaining of prolapse at follow‐up >2 years.
4.1
4.1. Analysis
Comparison 4 Pruritis, Outcome 1 Proportion of patients complaining of pruritis ani at final follow‐up.
4.2
4.2. Analysis
Comparison 4 Pruritis, Outcome 2 patients complaining of pruritis ani at follow‐up >2years.
5.1
5.1. Analysis
Comparison 5 Soiling/Difficulty with hygiene/Incontinence, Outcome 1 Proportion of patients experiencing soiling or diffiulty with hygiene or continence.
5.2
5.2. Analysis
Comparison 5 Soiling/Difficulty with hygiene/Incontinence, Outcome 2 fecal urgency.
5.3
5.3. Analysis
Comparison 5 Soiling/Difficulty with hygiene/Incontinence, Outcome 3 patients with hygiene/continence problems at follow up >1year but <2 years.
5.4
5.4. Analysis
Comparison 5 Soiling/Difficulty with hygiene/Incontinence, Outcome 4 patients with fecal urgency at follow up >2years.
6.1
6.1. Analysis
Comparison 6 Skin tags, Outcome 1 proportion of patients with peri‐anal skin tags at final follow‐up.
6.2
6.2. Analysis
Comparison 6 Skin tags, Outcome 2 patients with skin tags at follow up >1 year but <2years.
6.3
6.3. Analysis
Comparison 6 Skin tags, Outcome 3 patients with skin tags at follow up >2years.
7.1
7.1. Analysis
Comparison 7 Pain, Outcome 1 proportion of patients complaining of pain related to hemorrhoids at final follow‐up.
7.2
7.2. Analysis
Comparison 7 Pain, Outcome 2 patients complaining of pain at follow up >1year but <2years.
7.3
7.3. Analysis
Comparison 7 Pain, Outcome 3 patients complaining of pain at follow up >2years.
8.1
8.1. Analysis
Comparison 8 Recurrent hemorrhoids, Outcome 1 recurrent internal hemorrhoids seen at final follow‐up.
8.2
8.2. Analysis
Comparison 8 Recurrent hemorrhoids, Outcome 2 hemorrhoids at follow‐up >1 year but < 2years.
8.3
8.3. Analysis
Comparison 8 Recurrent hemorrhoids, Outcome 3 hemorrhoids at follow‐up >2years.
9.1
9.1. Analysis
Comparison 9 Stenosis/Outlet obstruction, Outcome 1 Proportion of patients complaining of difficulty voiding due to outlet obstruction or anal stenosis.
9.2
9.2. Analysis
Comparison 9 Stenosis/Outlet obstruction, Outcome 2 stenosis/outlet obstruction at follow up >1 year but <2 years.
9.3
9.3. Analysis
Comparison 9 Stenosis/Outlet obstruction, Outcome 3 stenosis/outlet obstruction at follow‐up >2years.
11.1
11.1. Analysis
Comparison 11 Additional Operations, Outcome 1 Further surgeries done later as a result of their initial operation (not peri‐operative).
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Update of

  • doi: 10.1002/14651858.CD005393

References

References to studies included in this review

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