Intervention Review

Stapled versus conventional surgery for hemorrhoids

  1. Kathleen J Lumb2,
  2. Patrick H.D. Colquhoun2,
  3. Richard Malthaner3,
  4. Shiva Jayaraman1,*

Editorial Group: Cochrane Colorectal Cancer Group

Published Online: 8 OCT 2008

Assessed as up-to-date: 15 MAR 2010

DOI: 10.1002/14651858.CD005393.pub2

Database Title

Additional Information

How to Cite

Lumb KJ, Colquhoun PH, Malthaner R, Jayaraman S. Stapled versus conventional surgery for hemorrhoids. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD005393. DOI: 10.1002/14651858.CD005393.pub2.

Author Information

  1. 1

    University of Toronto, Department of Surgery, Toronto, Ontario, Canada

  2. 2

    University of Western Ontario, Department of Surgery, London, Canada

  3. 3

    The University of Western Ontario, Division of Thoracic Surgery, London, Ontario, Canada

*Shiva Jayaraman, Department of Surgery, University of Toronto, St. Joseph's Health Centre, 30 The Queensway, Suite 221, Toronto, Ontario, M6R 1B5, Canada. jayars@stjoe.on.ca. shivaj76@yahoo.ca.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 8 OCT 2008

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Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

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 methods

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.

Authors' conclusions

Stapled hemorrhoidopexy is associated with a higher long-term risk of hemorrhoid recurrence and the symptom of prolapse. It is also associated with a higher likelihood of long-term symptom recurrence and the need for additional operations compared to conventional excisional hemorrhoid surgeries. Patients should be informed of these risks when being offered the stapled hemorrhoidopexy as surgical therapy. If hemorrhoid recurrence and prolapse are the most important clinical outcomes, then conventional excisional surgery remains the "gold standard" in the surgical treatment of internal hemorrhoids.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Conventional surgical hemorrhoidectomy results in fewer recurrences than stapled hemorrhoidopexy.

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 in 1998 as alternative to conventional excisional hemorrhoidectomy.  A review of randomized control trials comparing stapled hemorrhoidopexy and conventional excisional surgery was conducted. The results show that the stapled technique is associated with a higher risk of recurrent hemorrhoids and some symptoms in long term follow-up. Patients should be informed of these risks when being offered the stapled homorrhoidopexy as surgical therapy.

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

背景

環狀切除手術和一般手術對於痔瘡治療的效果

痔瘡是一種常見的肛門直腸疾病，MilliganMorgan開放性痔瘡切除術(MilliganMorgan open hemorrhoidectomy)是最常使用來治療痔瘡的手術技術，並且被認為是目前的「黃金標準」，1998年，Longo第一次提出使用痔瘡環狀切除術(Circular stapled hemorrhoidopexy)作為傳統痔瘡切除術替代手術的見解，一開始，只有一些針對痔瘡環狀切除術和傳統手術進行比較的小型隨機性對照試驗顯示，使用這個新痔瘡治療方法的患者較不容易感受到疼痛，且具有較快的復原速度，這些研究也推測患者對於痔瘡環狀切除術具有較高的接受度，並且較容易成為daycase手術(當日手術，不住院)，因此使其更經濟

目標

本研究的主要目的在於比較使用痔瘡環狀切除裝置和傳統切除技術治療患者痔瘡症狀的成效

搜尋策略

我們檢索了所有主要的電子資料庫(MEDLINE、EMBASE,和Cochrane Central Register of Controlled Trials(CENTRAL))，檢索資料的時間範圍由1998年至2006年5月

選擇標準

所有比較痔瘡環狀切除術和傳統痔瘡切除術治療效果的隨機性對照試驗都會被納入本研究中

資料收集與分析

所有的資料都會集中蒐集在資料表單中，在適當的情況下，會利用隨機效應模式來計算OR值

主要結論

在任何時間點進行追蹤時可以發現，使用痔瘡環狀切除術(SH)進行治療的痔瘡復發率會比使用傳統痔瘡切除方法(CH)的機率還要高(7個試驗，537位患者，OR值為0.85，95％的信心區間介於1.47至10.07之間，p = 0.006)，接受SH法治療的269名患者中有23名出現痔瘡復發的現象，但是接受CH法進行治療的268名患者中只有4名患者出現痔瘡復發，相同的，針對患者進行至少一年以上追蹤的試驗結果顯示，SH引發患者痔瘡復發的機率較高(5個試驗、417名患者、OR值為0.60，95％的信心區間介於1.24至10.49之間，p = 0.02)，此外，在所有時間點，接受SH法治療的患者抱怨出現脫垂症狀比例也明顯較高(8個試驗，798名患者、OR值為0.96，95％的信心區間介於1.33至6.58之間，p = 0.008)，若是術後針對患者持續進行追蹤一年以上，也會出現相同明顯的治療成果(6個試驗，628名患者，OR值為0.68，95％的信心區間介於0.98至7.34之間，p = 0.05)，SH法對於疼痛、肛門搔癢(pruritis ani)和急便(fecal urgency)等症狀並沒有明顯的影響，其他所有的臨床參數則偏向於支持使用CH治療

作者結論

相對於傳統痔瘡切除法來說，SH痔瘡治療法和長期性高痔瘡復發風險以及脫垂症狀有關，也可能與長期性的高症狀復發率有關，並且需要進行一些其他手術治療，如果欲使用SH痔瘡治療法的患者應該要被告知上述風險，如果痔瘡復發和脫垂現象是痔瘡治療的主要成果，那麼，除統治療切除手術仍是治療內痣手術的「黃金標準」

翻譯人

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌

總結

相對於傳統痔瘡切除術來說，SH痔瘡治療法具有痔瘡容易復發並出現脫垂現象的高風險，但是兩種手術方法都是安全的，在預防大多數臨床重要症狀上，傳統痔瘡切除法仍比SH痔瘡治療法更具優勢，如果痔瘡復發和脫垂現象被認定治療的重要臨床治療成果判斷依據，那麼傳統痔瘡切除法對於痔瘡治療仍具有「黃金標準」的位置，但是仍需要進行更多試驗來瞭解是否有特殊子集的患者可以由SH痔瘡治療法獲得較多的治療效益。

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