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What works best for haemorrhoids: stapled or conventional surgery?

The Milligan-Morgan open haemorrhoidectomy is the most widely practised surgical technique for haemorrhoids. Circular stapled haemorrhoidopexy (SH) was first described by Longo in 1998 as an alternative to conventional excisional haemorrhoidectomy (CH). Small randomised controlled trials have shown SH to be less painful and associated with quicker recovery. The objective was to compare the use of circular stapling devices and conventional excisional techniques in patients with symptomatic haemorrhoids.

Method We searched the major databases – Medline, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) from 1998 to May 2006. The selection criteria were all RCTs comparing SH to CH surgeries. Data was collected on a data sheet. When appropriate, an odds ratio was generated using a random effects model.

Main results Patients undergoing SH were

significantly more likely to have recurrent haemorrhoids in long-term follow-up

than those receiving CH (seven trials, 537

patients, OR 3.85, CI 1.47-10.07, p=0.006).

There were 23 recurrences out of 269

patients in the SH group versus only four

out of 268 patients in the CH group. Similarly, in trials where there was follow-up of

one year or more, SH was associated

with a greater proportion of patients with haemorrhoid recurrence (five 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

prolapse at all time points (eight studies, 798 patients, OR 2.96, CI 1.33-6.58, p=0.008). In studies with follow-up of more than one year, the same significant outcome was found (six studies, 628 patients, OR 2.68, CI 0.98-7.34, p=0.05). Non-significant trends in favour of SH were seen in pain, pruritis ani and faecal urgency. All other clinical parameters showed trends favouring CH.

Authors' conclusions Stapled haemorrhoid-opexy is associated with a higher long-term risk of haemorrhoid recurrence and the symptom of prolapse. It is also likely to be

associated with a higher likelihood of

long-term symptom recurrence and the need for additional operations compared

to conventional excisional haemorrhoid surgeries.

Patients should be informed of these

risks when being offered the stapled

haemorrhoidopexy as surgical therapy. If haemorrhoid recurrence and prolapse are the most important clinical outcomes, then conventional excisional surgery remains the 'gold standard' in the surgical treatment of internal haemorrhoids.

Reference Jayaraman S et al Stapled versus conventional surgery for haemorrhoids. Cochrane Database of Systematic Reviews 2006, Issue 4.

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