Circular Staplers for Hemorrhoids

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

Products
Hemorrhoidopexy staplers are specialized circular staplers that are used to resect excess prolapsed hemorrhoidal tissue and fix the rest of the hemorrhoidal tissue to the distal rectal wall. See image below.

Stapled hemorrhoidopexy. Image reproduced from original with permission of the American Society of Colon & Rectal Surgeons.

Category
Staplers, circular, hemorrhoidopexy

Device details
Covidien - EEA (end-to-end anastomosis) Hemorrhoid and Prolapse Stapler Set with DST Series Technology

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 Covidien and Ethicon instruments, offered in a 33-mm size, place two staggered circular rows of titanium staples and remove a circular tissue specimen. The Covidien stapler is offered with 3.5-mm or 4.8-mm leglength staples; the Ethicon stapler places 4-mm staples. The staplers are used in conjunction with a circular anal dilator 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 rectal bleeding, pain, pruritus, and prolapse. In the United States, up to one third of the 10 million people with hemorrhoids seek medical treatment, resulting in 1.5 million related prescriptions per year. Hemorrhoids plague all age groups, although they occur most often in individuals aged 46-65 years. Hemorrhoids are classified into internal and external hemorrhoids according to their anatomic origin within the anal canal and their position relative to the dentate line.

External hemorrhoids are located distal to the dentate line and cause pain when they thrombose. This area is covered with sensate squamous epithelium, so the patient typically reports pain, swelling, itching, or a combination of these symptoms. Internal hemorrhoids are located proximal to the dentate line. This area is composed of insensate columnar-glandular epithelium. 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, but retract with relaxation Grade II - Prolapse past the anal verge with strain, but reduce spontaneously Grade III - Prolapse past the anal verge with strain and must be reduced manually Grade IV - Chronic prolapse past the anal verge that is not reducible Stapled hemorrhoid surgery, or procedure for prolapsing hemorrhoids (PPH), was first described in 1997-1998, and has since become prominent. PPH is indicated mainly for treating symptomatic large internal hemorrhoids with a minimal external component that are not amenable to conservative and nonoperative therapies.[1, 2]

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

Clinical Trial Evidence

In a Cochrane meta-analysis of randomized, controlled clinical trials (RCTs) of PPH versus conventional excisional hemorrhoidectomy (CH), patients who underwent PPH were significantly more likely to have recurrent hemorrhoids in longterm follow-up at all time points than those who underwent CH (12 trials, 955 patients; odds ratio [OR], 3.22; confidence interval [CI], 1.59-6.51; P = 0.001). Patients with PPH were significantly more likely to complain of prolapse at all time points (13 studies, 1191 patients; OR, 2.65; CI, 1.45-4.85; P = 0.002) and were more likely to require an additional operative procedure (8 papers, 553 patients; OR, 2.75; CI, 1.315.77, P = 0.008). A nonsignificant trend in improved pain was associated 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 were very rare.[3] Nisar et al performed a systematic review of 15 randomized trials (1077 patients) comparing PPH and CH. They found that patients who underwent PPH had a shorter inpatient stay (weighted mean difference [WMD], -1.02 days; 95% CI, -1.47 to -0.57; P = 0.0001), shorter operative time (WMD, -12.82 minutes; 95% CI, -22.61 to -3.04; P = 0.01), and earlier return to normal activity (standardized mean difference, -4.03 days; 95% CI, -6.95 to -1.10; P = 0.007). Qualitative analysis showed PPH to be less painful than CH. However, PPH showed a higher recurrence rate (OR, 3.64; 95% CI, 1.409.47; P = 0.008) at a minimum follow-up of 6 months.[4] A systematic review by Tjandra and Chan of RCTs (1918 procedures) found that PPH offered significantly shorter

operating times (WMD, -11.35 minutes; P = 0.006), earlier return 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 experienced less pain, as evidenced by lower pain scores at rest and on defecation and 37.6% reduction in analgesic requirement. PPH also allowed a faster functional recovery with shorter time off work (WMD, -8.45 days; P< 0.00001) and earlier return 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). PPH was associated with less pain in the immediate postoperative period; shorter operating times, hospital stay, time to first bowel movement, and return to normal activity; but a higher rate of residual prolapse, prolapse in the longer term and reintervention for prolapse. There was no clear difference in the rate or type of complications associated with the two techniques. Burch et al also included a cost-effectiveness analysis that showed the two techniques to be similar overall.[6] A meta-analysis by Shao et al of 29 RCTs (2056 patients) also showed PPH to be associated with decreased pain in the early 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 compared with CH.[7]

Clinical Implementation
In PPH, a purse-string suture is placed in the mucosal and submucosal layers circumferentially, approximately 3-4 cm

above the dentate line. The hemorrhoidopexy stapler is placed and slowly closed around the purse string. Care is taken to draw excess internal hemorrhoidal tissue into the stapler. The stapler is fired, resecting the excess tissue and placing a double circular staple line above the dentate line. The result is resection of excessive internal hemorrhoidal tissue, fixation of the internal hemorrhoidal tissue left behind, and interruption of the arterial blood supply from above, inducing involution of the hemorrhoidal plexus (see image below)

Stapled hemorrhoidopexy. Image reproduced from original with permission of the American Society of Colon & Rectal Surgeons.

PPH can be performed as an outpatient procedure using general anesthesia or local anesthesia with intravenous sedation. For detailed descriptions of stapled hemorrhoidopexy, see the eMedicine articlesHemorrhoidectomy and Anal Surgery for Hemorrhoids.

Follow-up/Monitoring
Stool softeners can be used to ensure a more comfortable first bowel movement. Pain is usually most severe in the first 72 hours after the procedure and can be alleviated with

nonnarcotic analgesics. Pain is not exacerbated by bowel movements. The patient should be seen for a postoperative visit 4-6 weeks after the procedure, as a rectal examination can be tolerated at this point.

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

Anovaginal fistulas Substantial hemorrhage Retroperitoneal sepsis Rectal perforation

http://emedicine.medscape.com/article/1998243