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PPH & STARR

Minimally invasive procedures for haemorrhoids (PPH - rectal mucosectomy), rectal mucosal prolapse, rectal intussusception (RI) and rectal prolapse (STARR).

What are haemorrhoids?


Haemorrhoids or piles are swollen blood vessels in the anal canal (back passage). These blood vessels are part of our normal anatomy and play a role in keeping us continent; 1 in 3 people however go on to develop a problem with them at some stage of their life.


They are usually caused through constipation. Straining causes congestion of and eventually enlargement of the veins within the anal canal. They are more common during or after pregnancy. They can bleed, cause discomfort, a feeling of incomplete evacuation and may prolapse out of the anal canal causing a mucus discharge or soiling.
 
The traditional approach to haemorrrhoids is to excise them -

Milligan-Morgan Technique


Developed in London in 1937 by Messers Milligan and Morgan. The three major hemorrhoidal vessels are excised. In order to avoid stenosis, three pear-shaped incisions are left open, separated by bridges of skin and mucosa. This technique is the most popular method, and is considered the gold standard by which most other surgical hemorrhoidectomy techniques are compared.  

The operation has a reputation for pain and the wounds take 6-8 weeks to heal.






Ferguson Technique
Developed in the USA by Dr. Ferguson, in 1952. This is a modification of the Milligan-Morgan technique (above), whereby the incisions are totally or partially closed with absorbable running suture.

Furgeson Technique

A retractor is used to expose the hemorrhoidal tissue, which is then removed surgically. The remaining tissue is either sutured or is sealed through the coagulation effects of a surgical device.

Due to the high rate of suture breakage at bowel movement, the Ferguson technique brings no advantages in terms of wound healing (5-6 weeks), pain, or postoperative morbidity.

Conventional haemorrhoidectomy can be performed as a day-case procedure. But due to poor post-operative care in the community and high level of pain experienced after the procedure, an in-patient stay is often required (average of 3 days).


A minimally invasive approach PPH developed in Italy in 1997 was introduced into the UK almost 5 years ago. The technique allows patients to recover much faster from haemorrhoidal surgery and with less pain and fewer complications when compared to conventional excision surgery.  It is all very understandable when you see the final result (see below).  Bristol Laparoscopic Associates approach haemorrhoids almost exclusively using PPH.  In some patients with 4th degree haemorrhoids (allways prolapsed) a STARR procedure may be more effective.





PPH reduces/removes the prolapse, and in doing so pulls the haemorrhoids up into their normal position - a bit like a face lift.  It is used in secondary degree haemorrhoids when other measures eg repeated banding have failed and 3rd degree haemorrhoids (prolapse can be reduced manually). We have found it very useful in treating 4th degree (prolapsed out all the time) haemorrhoids provided that there is no high grade rectalanal intussusception.


What is HALO or THD

It is an operation that is suitable for certain types of haemorrhoids (piles). It is an abbreviation for “haemorrhoidal artery ligation operation”.

Which types of haemorrhoids are suitable for HALO?

The decision about whether your haemorrhoids are suitable for HALO will be made by your surgeon. Generally, HALO is effective for bleeding haemorrhoids that have not been improved by simple measures such as banding, injection or changes in diet. It can also be effective for some patients who are bothered by lumps or prolapse at the anus.

What other tests are necessary before the operation?

Your surgeon will sometimes want to check that your bowel is normal “above” the haemorrhoids and will recommend a telescope test such as a colonoscopy or flexible sigmoidoscopy.

What does the operation involve?

Whilst  the procedure can be performed under sedation, it is our preference to perform it under a general anaesthetic. The operation takes about 40 minutes to perform. A probe is inserted into the bottom and the blood vessels that supply the haemorrhoids (usually 6-8 in total) are detected so that the surgeon can put a stitch into them. These stitches cut off the blood supply to the haemorrhoids and make them shrink. Further stitches – recto anal repair RAR can then be placed to pull the loose haemorrhoidal tissue seen in grade 3 haemorrhoids up into the rectum.


What are the advantages of HALO?

The advantage of HALO is that the haemorrhoids are not removed and so there are no painful scars or wounds around the anus. The stitches that are put in by the surgeon are high enough up in the back passage that there is only minimal discomfort as there is little sensation at this level.  Recovery is usually measured in days.

How long does it take to recover?

Patients will usually be allowed home either the same day or after one night in hospital. People may wish to go back to work within a few days. Sometimes people will get some discomfort either within the

back passage or felt low down in the tummy, which may last a few days. It is common to get the temporary sensation of needing to open your bowels, even though they are empty, after the procedure.

What are the outcomes and risks of surgery?

Around 80% of people feel that symptoms are significantly improved or resolved after a HALO. The main risk of HALO is bleeding, which is a potential problem with all forms of haemorrhoid surgery. A few spots of blood is a common post-operative event but about 1 in 100 patients get bleeding which is heavier and does not stop. Typically, this occurs 3-7 days after surgery. If this is the case, you should seek medical advice.

 

What is STARR?


Evacuatory dysfunction in middle aged and older women is a common and often embarrassing condition.  Many are categorized as having constipation and irritable bowel syndrome.  It is estimated that 15% of women experience symptoms of constipation and/or obstructed defecation.  However, the true incidence is unknown as patients self medicate rather than consult their GP.

Obstructed defecation syndrome (ODS) is the normal desire to defecate, but with an impaired ability to evacuate the rectum.  ODS is invariably associated with rectoceles, rectal intussusception, occult rectal prolapse, rectal mucosal prolapse and in some cases, concurrent genital prolapse.

Whilst it is most commonly seen in multiparous females, it is increasingly seen in nulliparous women and males.  The greatest single factor that has brought this undercurrent of patients to light has been the introduction of the two week wait fast track cancer referral system.  Middle aged women are health conscious and present to the GPs with urgency, obstructed defecation, incomplete emptying, prolonged toilet time, use of laxatives or loperimide, the need for perineal support or manual digitation to facilitate evacuation in addition to pelvic pain, rectal bleeding etc.  A TWW appointment is made and a change of bowel habit investigated.  Straight to test barium enema and colonoscopy will not pick up these patients.  The history is very classic and the sigmoidoscopic findings consistent.

Traditional management for ODS, including dietry manipulation, laxatives, enemas, pelvic floor physiotherapy, biofeedback and a variety of surgical repairs aimed at excisiong the rectocele (posterior colporraphy) and intussusception are largely unsuccessful.  In our opinion, tradittional gynaecological opperations make things worse and should only be considered cosmetic at best.
 
Stapled Trans Anal Rectal Resection pr STARR is a new treatment option that is being offered in the European Union, Australasis, USA and increasingly in the UK.  The procedure has arisen out the stapled haemorrhoidopexy which has been used in treating haemorrhoids.

It was Antonio Longo (Milan & Vienna) who having developed PPH extended his theories on haemorrhoid prolapse and applied them to the management of ODS.  Having started PPH in early 1999.


 
Bristol Laparoscopic Associates, independant of Longo, quickly realised the potential of using the same staple guns used in stapled haemorrhoidectomy to not only manage patients with ODS but all patients with symptomatic rectal intussusception.  Not everyone who has haemorrhoids (see above) has haemorrhoids; many will have both a rectocele (bulge of rectum into the vagina) as shown.

The occult prolapse or intussception is shown below.  STARR removes this tissue.


We initially termed the procedure stapled rectal mucosectomy (cf., Delormes rectal mucosectomy).  It has been our experience (>300 cases) that the STARR procedure is not only safe but has surprisingly high efficacy and that the good outcomes are maintained over the short term (medaian follow-up of 230 patients is 2 years). 


The final immediate cosmetic result (shown below) is excellent.  Further improvement will occur in the postoperative period.


STARRs efficacy is supported by its rapid uptake in the UK eg >150 procedures were performed by surgeons in the SW in 2006. 














Stapled haemorrhoidopexy/pph

NICE guidance HALO
What is PPH - Stapled Haemorrhoidopexy
2007 NICE guidance
BLAs experience of PPH
Circumferential stapled haemorrhoidopexy(PPH) in the management of 3rd and 4th degree haemorrhoids

Stapled Trans Anal Rectal Mucosectomy STARR

STARR for high-grade haemorrhoids
BLAs experience of STARR (medium term)
STARR for outlet obstruction (ODS) and symptomatic intussusception
NICE guidance STARR
STARR website
UK colorectal surgeons offering STARR

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SPIRE Hospital, Bristol. 
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Contact: Claire Trenberth - 0117 9804051
claire.TRENBERTH@spirehealthcare.com
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