Hemorrhoidectomy is a common procedure that usually obtains good results and high patient satisfaction; however, the procedure is uncomfortable and requires an average of two weeks away from work. Stapled hemorrhoidectomy (or stapled anopexy) was developed to avoid making an incision in the anal canal, thereby lessening the pain and permitting a more rapid return to normal activities. Despite a lack of published evidence, this procedure rapidly became popular in Europe, where an estimated 50,000 such procedures have been performed. Results from randomized, controlled trials confirming the effects have since been published, but long-term efficacy remains unknown. Cheetham and colleagues conducted a randomized, controlled trial comparing stapled hemorrhoidectomy to conventional diathermy hemorrhoidectomy, but the trial was suspended because of adverse postoperative effects.
Stapled hemorrhoidectomy was performed on 22 patients: seven in a pilot study and 15 in a randomized, controlled trial. One surgeon performed all of the procedures. The standard perioperative care consisted of lactulose, metronidazole and analgesics. The patients used a visual analog scale to assess pain on each of the first 10 postoperative days. Follow-up assessments occurred at 10 days, six weeks and six months following surgery.
Of the 22 patients who underwent surgery, 16 were followed for more than six months, and five (31 percent) of the 16 patients developed symptoms of postdefecatory anal pain and fecal urgency for up to 15 months following surgery. Two patients were unable to continue their normal activities because of symptoms. On examination, the five affected patients had diffuse tenderness at the staple line without signs of local sepsis. Areas of rectal muscle were found in four of the five affected patients but in one of the 11 unaffected patients. The cause of the pain and urgency was unclear. The staple lines were at the correct height within the anal canal, and endoanal ultrasonography revealed the anal sphincters to be intact. The smooth muscle inclusion in the doughnut could be regarded as relevant to the symptoms of pain in four of the five affected patients; however, muscle inclusion was not considered an adequate explanation because one unaffected patient also had muscle inclusion.
The authors conclude that a disturbingly high proportion of patients developed persistent, severe pain and fecal urgency following stapled hemorrhoidectomy, and the long-term complications following this procedure outweigh the benefits of decreased postoperative pain. They advise all surgeons who have performed stapled hemorrhoidectomy to assess those patients for any unusual long-term pain or fecal urgency. The authors further recommend a more cautious approach toward choosing this procedure.
editor's note: This study illustrates the reason that surgical procedures must be subjected to controlled trials just as other treatment modalities are. It also shows that common, even “mundane” conditions merit serious scientific study. Most importantly, it emphasizes that because of increasingly fragmented health services, adverse effects may not be perceived because the patients may not be followed by the original surgeon. One wonders how many primary care physicians are struggling to explain unexpected and persistent symptoms in patients following stapled hemorrhoidectomy—and how many patients have been suspected of “nonorganic” pain.—A.D.W.