Applied Evidence

A new treatment option for grades III and IV hemorrhoids

Author and Disclosure Information



The stapling technique markedly reduces swelling by disrupting the hemorrhoidal artery blood flow, thereby reducing inflow to the hemorrhoids themselves. In addition, restoring the internal hemorrhoids to their normal anatomic position prevents prolapse and alleviates patients’ symptoms.11 The staples are placed well above the dentate line, and the majority of PPH is performed where there are autonomic nerve fibers, as opposed to somatic innervation. Thus, patients who undergo PPH tend to experience less postoperative pain than do those who undergo conventional hemorrhoidectomy, which involves the cutting of innervated perianal skin. Notably, the function and morphology of the internal anal sphincter, which have a direct bearing on anal continence, are not typically affected by PPH.12 Moreover, in patients with preoperative sensory impairment, the procedure improves anal-canal sensitivity—that is, the ability to distinguish between air and warm water in the anal canal.12 In contrast, research has shown that only about half of the patients who undergo conventional hemorrhoidectomy are able to detect water in the anal canal after surgery, and an additional 25% lose this ability within 6 months of the operation.13 Loss of anal-canal sensitivity affects internal-anal-sphincter function and morphology, which in turn affects anal continence.

Since 2000, several studies have been published confirming that PPH is associated with a low rate of compli-cations.14-16 Rare instances of sepsis following PPH have been reported. Some clinicians recommend administration of prophylactic antibiotics prior to the procedure. Guy and Seow-Choen suggest that the potential for sepsis is high only in cases where an excess amount of muscle is incorporated into the stapler housing. Thus, in recent years, the surgical technique has been refined so as to reduce the potential for postoperative infection.17,18

Randomized controlled trials

PPH versus other methods

Many individuals with extensive hemorrhoidal prolapse may not want to undergo, or will not be candidates for, any type of surgical intervention. For such patients, RBL is a viable option. Indeed, a number of studies endorse RBL as a first-line option for grade III hemorrhoids. However, one should note that RBL carries a high potential for symptomatic recurrence, which often results in the need for multiple bandings.19,20

Peng and colleagues conducted a study in which 55 patients with grade III or small grade IV hemorrhoids were randomized to either RBL or PPH.19 There was a higher incidence of pain at discharge and at 2-week follow-up in the PPH group (P<.001). Six patients in the PPH group experienced procedure-related complications, as opposed to none in the RBL group (P=.027). Despite these results, the authors recommended PPH for patients who did not want to run the risk of requiring further interventions. Notably, the group that underwent RBL had a significantly higher incidence of recurrent bleeding at 2 weeks’ follow-up (68% vs 27%, P=.002). More important, 5 patients in the RBL group needed to undergo excisional hemorrhoidectomy to resolve persistent bleeding or prolapse, whereas none of the PPH patients required further intervention (P<.05).

The earliest randomized controlled clinical trials directly comparing PPH with conventional hemorrhoidectomy reported excellent results21,22; however, patient numbers were small, and, of course, no long-term data were available. Now, reports are in from larger trials and studies with longer-term follow-up.

Shalaby and Desoky conducted a trial in which 200 patients were randomized to either Milligan-Morgan hemorrhoidectomy or PPH. Compared with hemorrhoidectomy, PPH required less operating time (9.0 vs 19.7 minutes, P<.001) and a shorter hospital stay (1.1 vs 2.2 days, P<.001), and provided a faster return to full activity (8.2 vs 53.9 days, P<.001).23 In addition, pain scores were significantly lower in the stapled group after the first 24 hours, at the time of first bowel movement, and at 1 week postoperatively (TABLE 1).

In a 100-patient, prospective, randomized trial, Ganio and colleagues compared PPH with open hemorrhoidectomy and found PPH to be as effective as conventional surgery.24 Postoperative bleeding occurred in 3 patients in each group. However, reduced postoperative pain, a shorter hospital stay, and a trend toward a quicker return to work were reported for the group of patients who underwent PPH. Moderate pain for hemorrhoidectomy patients occurred for a median of 5.3 days (range, 0–19 days) compared with only 3.1 days (range, 0–10 days) in the PPH group. Hemorrhoidectomy patients complained of severe pain for 2.3 days (range, 0–24 days), whereas the PPH patients had only 1 day (range, 0–14 days) of severe pain (P=.01). Functionally, the investigators found no difference between the 2 groups with respect to postoperative fecal incontinence. But, at 1 month, patients in the hemorrhoidectomy group were significantly less continent to flatus.25 The patients who underwent PPH also showed a statistically significant improvement in constipation scores, unlike the group who underwent conventional surgery.

Next Article: