Applied Evidence

A new treatment option for grades III and IV hemorrhoids

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In another study, Palimento and colleagues used several methods to evaluate postoperative pain in a group of 74 patients randomized either to PPH or open hemorrhoidectomy.26 Patients were encouraged to ask freely for pain relief, and the amounts of analgesic consumed were recorded. A visual analogue scale (VAS) from 0 (no pain) to 10 (worst pain imaginable) was completed by each patient at 4 and 24 hours following surgery. The researchers also requested a VAS score to evaluate pain at first defecation. In addition, patients were asked to record when they were able to have completely pain-free bowel movements and when there was pain-free return to normal activities and work. Analgesia requirements were similar between the 2 groups. Median VAS scores in the PPH group were significantly lower than in the open-hemorrhoidectomy group at 4 and 24 hours postoperatively and after first defecation (TABLE 2).

No statistically significant difference between the groups was found for incidence of postoperative bleeding. Nor did the groups differ regarding return to normal activities or return to work. However, the investigators noted that many factors affect the latter 2 outcome measures, including a patient’s motivation and his/her insurance coverage for disability, making comparisons somewhat unreliable. Hence, time to resumption of pain-free defecation was evaluated as a more objective measure and was found to be significantly less in the stapled group (10 vs 12 days, P=.001). At long-term follow-up (median, 17.5 months; range, 10–27 months), occasional pain was reported by 6 (16.2%) of the 37 patients in the PPH group and by 7 (18.9%) of the 37 patients in the open-hemorrhoidectomy group (P=1.000).

Racalbuto and colleagues performed a long-term randomized trial comparing results for 50 patients who underwent PPH with another 50 who underwent Milligan-Morgan hemorrhoidectomy.27 Patients were followed over a period of 48 months. Once again, patients who underwent PPH experienced significantly less pain and therefore were able to return to activities much more quickly than those who underwent conventional hemorrhoidectomy (8.04 ± 1.37 days vs 16.9 ± 2.50 days, P<.0001). In the long-term follow-up evaluation, none of the patients in either treatment group experienced stenosis. In addition, when comparing the 2 groups with respect to anal incontinence and recurrence of prolapse, the investigators did not find any significant differences.


Mean Pain Scores for PPH vs Milligan-Morgan Hemorrhoidectomy

PPH Mean (SD)Milligan-Morgan Mean (SD)P Value
First 24 hours2.5 (1.3)7.6 (0.7)<.001
First bowel movement1.1 (0.3)6.6 (1.2)<.001
1 week after operation0.4 (0.7)2.6 (0.6)<.001
PPH = procedure for prolapse and hemorrhoids; SD = standard deviation.
Adapted from Shalaby and Desoky.23


Median Pain Scores for PPH vs Open Hemorrhoidectomy

PPH Median (range)Open Hemorrhoidectomy Median (range)P Value
4 hours after operation4 (2–6)5 (2–8).001
24 hours after operation3 (1–6)5 (3–7).000
First defecation5 (3–8)7 (3–9).000
PPH = procedure for prolapse and hemorrhoids.
Data from Palimento et al.26

Contraindications to PPH

Contraindications to PPH include anal stenosis, that is, an anal canal that does not allow the stapler to be inserted. The PPH procedure also should be avoided in patients with an anorectal abscess, a complex fistula in ano, and perianal Crohn’s disease. As with any other type of surgery, patients undergoing anticoagulation therapy must be carefully evaluated.


The stapling technique is the newest treatment option for grades III and IV hemorrhoids. Although more randomized trials are needed, it appears from the research thus far that PPH is effective, with the potential to involve less pain and a shorter recovery time than conventional hemorrhoidectomy.


Dr Parker serves as a consultant to Ethicon Endo-Surgery. This supplement is supported by a grant from Ethicon Endo-Surgery.

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