Stapling of hemorrhoids — a relatively new and increasingly popular procedure — is associated with a higher risk of recurrence and prolapse than conventional hemorrhoid removal surgery, investigators report in a comprehensive review of clinical studies.
In contrast to removal (excisional) surgery, circular stapling (hemorrhoidopexy) does not remove hemorrhoids but treats them by inhibiting blood flow to the tissue.
"This study shows that stapled hemorrhoidopexy is associated with a greater risk of hemorrhoid recurrence and the symptom of prolapse in long-term follow-up compared to conventional excisional surgery," said lead investigator Shiva Jayaraman Colquhoun, M.D.
"If surgeons are to offer this novel technique to their patients, there should be an informed discussion of the risks," said Colquhoun, a resident in general surgery at the Schulich School of Medicine and Dentistry, University of Western Ontario, in Canada.
The review appears in the current issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates research in all aspects of health care. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing trials on a topic.
Hemorrhoid disease is known to affect more than 15 million people annually in the United States, a number believed to be low since an estimated one-third of patients with symptoms of hemorrhoids do not seek a physician's care for the condition.
Stapling was introduced in the late 1990s, and in some small studies was shown to be less painful and faster to heal than conventional surgery. A few short-term studies — with less than a year of follow-up — suggested that stapling is equal to excision for controlling further hemorrhoid symptoms. These results helped lead to growing demand for the stapling procedure.
For this new review, the investigators analyzed seven randomized clinical trials involving 537 participants and found that patients who had undergone circular stapling were significantly more likely to have recurrent hemorrhoids in the long term than those whose hemorrhoids were surgically removed.
Out of 269 stapling patients, 23 suffered recurrences, compared with four recurrences among 268 patients in the surgical-removal group.
The investigators also found that a significantly higher proportion of stapling subjects complained of prolapse (protrusion outside the anus) both within 12 months and longer.
In favor of stapling, results were better in terms of less pain, itching or bowel-movement urgency; however, these were data "trends" that did not reach the level of significance All other clinical outcomes favored excisional surgery.
The authors suggested that rather than simply offering stapling to all patients with hemorrhoids, there may be a subset of patients for whom it is more beneficial, and that identifying this subset will require further research. "If hemorrhoid recurrence and prolapse are the most important clinical outcomes," they said, "then conventional excisional surgery remains the 'gold standard' in the surgical treatment of internal hemorrhoids."
"This paper directly confronts the major concern with stapled hemorrhoidectomy, namely the long-term outcome," said Joshua Katz, M.D., in private practice with Montgomery Colorectal Surgery in Rockville, Md. "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."
"In all fairness," Katz added, "the increased risk, although statistically significant, is still clinically acceptable, 23 of 269 [stapled] patients versus four of 268 patients with conventional hemorrhoidectomy. 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."