Case Study: Stapler surgery for hemorrhoids or piles

Summary

Surgery for hemorrhoids or piles will leave a wound at each of the removed pile areas. This usually takes a few weeks to heal, thereby causing pain, bleeding and discomfort for the patient. With the advancement in technologies, stapler surgery for hemorrhoids or piles has been a boon for the aggressive grade-3 or 4 prolapsing piles. We describe a short case of a 45-year-old male with grade-3 hemorrhoids with his treatment and outcome after stapler surgery for piles.[s2If is_user_logged_in()]piles gr4 at 3[/s2If]

Background

Piles or hemorrhoids are a common disease, which is unique to mankind owing to our erect postures. Normally any problem around the anus is called “piles” or “hemorrhoids” by a lay person. There are 4 stages of internal hemorrhoids. The first & second stage piles can be treated without surgery by sclerotherapy, suction band ligation, and IRC (infra-red coagulation). The advanced grade 3 and 4 piles or hemorrhoids need surgery, which can be open or closed hemorrhoidectomy, laser excision, BUSH (bloodless ultrasonic scalpel surgery for hemorrhoids) and stapler surgery. The stapler surgery has proven and promising results and is therefore now[s2If !is_user_logged_in()]…

[/s2If][s2If is_user_logged_in()] a treatment of choice for late stage piles.pph donut1

 

Case Presentation

This 45-year-old male patient presented with swelling coming out of the anus every time he passed stools. Earlier, it used to go back inside the anus on its own, but since a few weeks, he has had to push it back inside. On investigation, he was an otherwise healthy person with all normal reports and grade-3 circumferentially prolapsing hemorrhoids or piles.pph donut on2

Surgery was completed with general anesthesia using the pile stapler. The surgery lasted 12 minutes and the patient was discharged after 6 hours with advice of medications, laxatives and a sitz bath.

At 1 week, the patient had no symptoms of piles, his stools were normal and he was back to his basic activities. At 3- and 8-week follow-ups, the patient had practically forgotten about his problem and was busy with his day-to-day life.pph end result no4

Discussion

Stapled hemorrhoidopexy or MIPH (minimally invasive procedure for prolapsing hemorrhoids) has revolutionized the treatment of advanced 3rd and 4th degree piles.

God has made anal cushions with an intention to make our anus an air-tight & water-tight junction. So these are required to maintain perfect control on our stools. Cutting them away as in conventional piles surgery can jeopardize the control over our motions. This can be avoided using the stapler.
Conventional surgery for hemorrhoids will leave wounds at three sites (3, 7, and 11 o’clock positions when the patient is in lithotomy/delivery position). Until these wounds heal in 1 to 1.5 months, the patient has to bear pain every day while passing stools and also throughout the day. There is also bleeding from the raw area, along with the potential chance of secondary infection and gangrene until the wounds heal.

In MIPH, the sliding loose wall of the rectum is cut circumferentially, the sagging anal cushions are pulled-up back in their position where they belong, and the raw area is stapled in a single step using the advanced and most effective stapler. Thus there are distinct advantages over conventional surgery as follows:

Advantages of MIPH over conventional surgery for piles

   MIPH / stapled hemorrhoidopexy              Conventional surgery       
No wound outside the anus Three large wounds at the anal margin
Pain is 80% less Painful wounds until they heal (4 to 6 weeks)
No bleeding during or after surgery Bleeding from raw wounds until they heal
Total circumferential removal of piles from their roots where they start Removal of only the large swollen piles. The ones left in between have the potential to grow and recur in future, because only the effect is tackled, but the cause remains uncured
God-made natural anal cushions preserved. Thus control over our motions is excellently preserved Cushions are cut away from the body, permanently thus violating God’s intention to keep our anus as an air-tight & water-tight opening which is controlled by our will
Resume regular activities as early as the second day after surgery Need to take rest (due to pain & bleeding) for at least 2 weeks until the patient feels comfortable and confident to go out of the house

Learning Points/Take Home Messages

In view of the best outcome and results for our patients, we should be aware of the existence of a way of treating piles using a stapler, which causes significantly less pain, less bleeding and removes the piles or hemorrhoids completely. We should offer this modality of “stapler surgery for piles or hemorrhoids” to selected deserving patients who have grade 3 or grade 4 piles only, in order to alleviate their sufferings.

About The Author

Gore
Dr. Pravin Gore, Laproscopic Colon-Rectal Surgeon & Proctologist, Bhatia hospital, Mumbai, India. e-mail: drpravingore@gmail.com / www.pilesfreedom.com

 

Sources:
Yang J, Cui PJ, Han HZ, Tong DN., Meta-analysis of stapled hemorrhoidopexy vs LigaSure hemorrhoidectomy, World J Gastroenterol. 2013 Aug 7;19(29):4799-807. doi: 10.3748/wjg.v19.i29.4799. http://www.wjgnet.com/1007-9327/pdf/v19/i29/4799.pdf

Lee KC, Chen HH, Chung KC, Hu WH, Chang CL, Lin SE, Tsai KL, Lu CC., Meta-analysis of randomized controlled trials comparing outcomes for stapled hemorrhoidopexy versus LigaSure hemorrhoidectomy for symptomatic hemorrhoids in adults, Int J Surg. 2013 Jul 19. doi:pii: S1743-9191(13)01013-3. 10.1016/j.ijsu.2013.07.006. http://www.sciencedirect.com/science/article/pii/S1743919113010133

Lohsiriwat V., Approach to hemorrhoids, Curr Gastroenterol Rep. 2013 Jul;15(7):332. doi: 10.1007/s11894-013-0332-6. http://www.ncbi.nlm.nih.gov/pubmed/23715885

Kim JS, Vashist YK, Thieltges S, Zehler O, Gawad KA, Yekebas EF, Izbicki JR, Kutup A., Stapled hemorrhoidopexy versus milligan-morgan hemorrhoidectomy in circumferential third-degree hemorrhoids: long-term results of a randomized controlled trial, J Gastrointest Surg. 2013 Jul;17(7):1292-8. doi: 10.1007/s11605-013-2220-7. Epub 2013 May 14. http://www.ncbi.nlm.nih.gov/pubmed/23670518

Ammaturo C, Tufano A, Spiniello E, Sodano B, Iervolino EM, Brillantino A, Braccio B., Stapled haemorrhoidopexy vs. Milligan-Morgan haemorrhoidectomy for grade III haemorrhoids: a randomized clinical trial, G Chir. 2012 Oct;33(10):346-51. http://www.ncbi.nlm.nih.gov/pubmed/23095566

Pramateftakis MG, Pavlidis L, Koumourtzis M, Sxisas N, Rampiadou C., The use of a detachable anvil enables an easier and safer stapled hemorrhoidopexy, Tech Coloproctol. 2012 Oct 18 http://www.ncbi.nlm.nih.gov/pubmed/23076287

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