Stapled Haemorrhoidectomy

Many individuals around the globe will suffer from haemorrhoids at some stage in their lives, particularly as they get older. Haemorrhoids – swollen veins in the anal or rectal area – occur when too much strain is placed on haemorrhoidal cushions, causing them to become inflamed, swell, and sometimes even bleed.

In most cases, haemorrhoids can be dealt with effectively through home remedies or over-the-counter solutions. However, in more extreme cases, surgery is required.


What exactly is a stapled haemorrhoidectomy?

Stapled haemorrhoidectomies (or haemorrhoidopexies) are most often used to treat third-degree haemorrhoids, which protrude from the anus as a result of straining during a bowel movement. A stapled haemorrhoidectomy procedure doesn’t actually remove haemorrhoids themselves, but instead, the loosened, expanded tissue around them is pinned back, halting the prolapsed effect.

“Stapling”, as it’s also known, is a relatively-new approach to treating haemorrhoids, and only became widespread in the late 90s. Some small-scale studies carried out on the procedure concluded that it was less painful than traditional haemorrhoidectomies and also healed faster. It was also suggested that stapling controlled future recurrence of haemorrhoid symptoms just as effectively as traditional approaches, leading to increased popularity and interest in the procedure.


How does it work?

During the stapled haemorrhoidectomy procedure, a hollow, circular tube is carefully inserted into the anal canal, through which a suture is threaded and woven into the anal canal above the internal haemorrhoids – the suture ends are drawn back out of the anus through the tube. A surgical stapler is pushed through the first tube and the lax haemorrhoid tissue below the haemorrhoid is pulled into the stapler’s jaws. When the suture is pulled, the haemorrhoid cushions are returned to their natural position in the anal canal, after which the stapler is triggered, cutting off the circumferential ring of excess tissue, sealing it at the upper and lower edges.


How long does the procedure take?

A stapled haemorrhoidectomy takes less time than a traditional haemorrhoidectomy (roughly half an hour), and is normally much less painful. Those who undergo the procedure are normally able to return to work faster than those on whom a traditional haemorrhoidectomy is administered. If your stapled haemorrhoidectomy is a day procedure, you’ll be able to go home once the anaesthetic has worn off and you can eat and drink comfortably. Patients may need someone to stay with them for 24 hours post-surgery to ensure they remain safe and stable.


Who should have a stapled haemorrhoidectomy?

People suffering from either internal or external haemorrhoids can turn to stapled haemorrhoidectomies as potential solutions to their problems. The procedure is normally used to treat third or fourth-degree haemorrhoids, though it can also be used for second-degree haemorrhoids that extend outside the anus during a bowel movement but retreat again of their own accord. Third-degree haemorrhoids must be pushed back into the anus following a bowel movement, but fourth-degree haemorrhoids will always remain outside and visible.

In some cases, a stapled haemorrhoidectomy can be combined with the removal of the external portion of the haemorrhoid to alleviate the problem, though if the external haemorrhoid is big enough, both the internal and external portions of the haemorrhoid may need to be removed through a traditional surgical haemorrhoidectomy.


Where do the staples go after surgery?

In the course of a stapled haemorrhoidectomy, the blood vessels within the haemorrhoid tissue that feed the haemorrhoid vessels themselves are cut off, effectively reducing the overall size of the haemorrhoid. While the damaged tissue around the haemorrhoid heals following the procedure, the scar tissue locks the haemorrhoidal cushions higher in the anal canal. Once the tissue has healed, the staples simply drop off and are passed in stool. Patients are unlikely to ever notice their staples passing.


Are there any complications with stapled haemorrhoidectomies?

Though stapled haemorrhoidectomies are more popular than ever, they are generally associated with a high risk of recurrence than the forms of haemorrhoid surgery normally performed, primarily because a stapled haemorrhoidectomy only reduces blood flow to loosened tissue rather than removing the haemorrhoid entirely, as would be the case in sclerotherapy, coagulation therapy or haemorrhoidal artery ligation.


The recurrence issue

A review published in The Cochrane Library analysed seven randomised clinical trials in which 537 people participated, the results of which showed that those who had undergone stapled haemorrhoidectomies were much more likely to experience recurrences of the condition than those who had their haemorrhoids removed completely. From a pool of 269 stapling patients, 23 suffered recurrences; in comparison, only four people from the surgical-removal group experienced recurrence of the condition. A substantial number of stapling patients also experienced haemorrhoid prolapse within and beyond a year of their procedures taking place, though the stapling approach was preferable in regard to pain, itchiness and the necessity for bowel movements.

“This study shows that stapled haemorrhoidopexy is associated with a greater risk of hemorrhoid recurrence and the symptom of prolapse in long-term follow-up compared to conventional excisional surgery,” explained Shiva Jayaraman Colquhoun, lead investigator in the study.

A general surgery resident at the University of Western Ontario also commented: “If surgeons are to offer this novel technique to their patients, there should be an informed discussion of the risks.

“This paper directly confronts the major concern with stapled haemorrhoidectomy, namely the long-term outcome,” an MD in private practice added.

“Proponents of this procedure argue it provides similar results to the open procedure with less pain, less disability and more rapid return to work. This paper states that the decreased pain and disability may entail increased risk of recurrence. As the authors note, patients must be advised of this increased risk.”

He concluded: “In all fairness, the increased risk, although statistically significant, is still clinically acceptable, 23 of 269 [stapled] patients versus four of 268 patients with conventional haemorrhoidectomy.

“Physicians and patients will therefore choose between a procedure carrying increased morbidity and disability with a low recurrence rate, and a procedure with decreased morbidity and disability and a higher recurrence rate.”

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