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STARR for high-grade haemorrhoids

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08/03/2014

High-grade haemorrhoids - a manifestation of an underlying pelvic floor disorder? The role of STARR in its treatment

 

Hardy A,  Carter H*, Dixon AR

Depts of Laparoscopic Colorectal & Pelvic Floor Surgery, and *GI Radiology, Frenchay Hospital, North Bristol NHS Trust, Bristol, UK

 

 

 

Keywords: STARR, haemorrhoids, obstructed defaecation, internal rectal prolapse

 

 

 

 

 

 

 

 

Abstract

Purpose: To establish the incidence of haemorrhoidal disease in patients undergoing stapled transanal rectal resection (STARR) for obstructed defaecation syndrome (ODS) and internal rectal prolapse (IRP), and the results of surgical intervention.

Methods:  Examination of prospectively collected electronic databases of Stapled Haemorrhoidopexy (PPH) and STARR since 2002.  In 2006 we abandoned PPH as a treatment of grade IV haemorrhoids in favour of STARR.

Results:  Of 390 patients (245 female, 63%) undergoing STARR for symptomatic ODS and IRP over a 9-year period, 139 (36%) had grade IV and 168 (43%) grade III haemorrhoids. 210 (54%) had undergone previous outpatient bandings, 37 (9%) Milligan-Morgan haemorrhoidectomy (MMH), and 14 (4%) stapled haemorrhoidopexy (PPH) during the previous 5 years.  26 of the 37 (70%) MMH patients had recurrent high-grade (III or IV) haemorrhoids. 13 of the 14 PPH patients (93%) had recurrent high-grade haemorrhoids.  47% of patients with symptomatic Oxford grade IV IRP had coexisting high-grade haemorrhoids.  Recurrent symptoms after STARR for patients with haemorrhoids and IRP were no higher than in those without haemorrhoids.  Quality of life scores were comparable between the two groups.  86.2% of patients expressed significant improvement in their symptoms after STARR.

Conclusions:  There is a high incidence of haemorrhoids in patients that present with ODS and pelvic floor dysfunction.  Haemorrhoids themselves may present with ODS.  Treating the haemorrhoids alone may fail if the underlying pelvic floor disorder is not rectified.  STARR is safe and effective.  In these cases, it successfully treats the haemorrhoids by addressing the underlying IRP.

 

Introduction:

Although haemorrhoids have been treated for centuries, it is only in the last forty years that anatomical studies have begun to explain their pathophysiology.  Thomson’s landmark work in the 1970s was based on post-mortem dissections and histological examination of the vasculature of the anal canal [1].  In these he demonstrated discrete dilations within the haemorrhoidal plexus, concentrated in pads of tissue which he called ‘anal cushions’.  Having reviewed the various theories of haemorrhoid aetiology, Thomson concluded that it was downward displacement of these engorged anal cushions, which led to the formation of haemorrhoids.  Haas followed up these histological studies a decade later with his own work concentrating on the connective tissue stroma of the submucosa, surrounding the vessels of the haemorrhoidal plexus [2].   The anal cushions were shown to be supported by a scaffold of connective tissue fibres arising from the conjoined longitudinal coat of the rectum.  Within this were islands of smooth muscle and elastin fibres.  These connective tissue supports were stretched and fragmented in haemorrhoids. This lent further support to the ‘sliding anal canal’ theory.  More recent work has concentrated on the role of collagen within the submucosa, and particularly the ratio of different collagen types in haemorrhoids [3].  Where previous theories of haemorrhoid aetiology have concentrated on their vasculature, it is now appreciated that connective tissue changes are likely to be the most important factor in haemorrhoidal prolapse.  Haemorrhoids are conventionally graded from I-IV on the basis of the degree of prolapse rather than symptom severity.   Treatment is largely based on addressing this prolapse through banding, haemorrhoidal artery ligation, stapled anopexy (PPH) or a more traditional excision haemorrhoidectomy. 

Longo [4], like ourselves and others [5], believes that haemorrhoidal prolapse is part of the continuum of internal rectal prolapse that in many cases extends to full thickness external prolapse, and that rectal mucosal prolapse is important in its pathophysiology. Large case series demonstrate that grade III haemorrhoids are frequently associated with disorders of continence (25%) and evacuation (40%) with over a third admitting to having symptoms of ODS (straining, incomplete evacuation). Recurrent prolapse tends to occur anteriorly where IRP has its origins [6].  Stapled transanal rectal resection (STARR) has proved successful in the short [7,8] and medium term [9] in treating patients with ODS and symptomatic IRP.  One finding commonly seen during PPH is that the CAD (circular anal dilator) often demonstrates co-existing IRP or high-grade intussusception of the lower rectum [10,11].  Some have suggested that PPH is prone to early recurrence because the housing of the PPH-03 (Ethicon Endosurgery, Bracknell, UK) stapler is only capable of accommodating and excising a limited amount of mucosa [12].

In patients with grade IV haemorrhoids, the choice of surgery lies between conventional excision haemorrhoidectomy, the consideration of a modified PPH resection[13] or a double stapled PPH technique [10,14,15].  This study examines the relationship of high-grade haemorrhoidal disease with pelvic floor disorders and reports the effect of their treatment by a modification of the STARR technique.

 

Patients and methods:

We have kept a password-protected computerised prospective database of all PPH and STARR procedures performed since 2002.  The indications for STARR were ODS and symptomatic IRP having failed a trial of at least 3 months of conservative management with dietary modifications, laxatives and biofeedback therapy. In 2006 we abandoned PPH in patients with symptomatic grade IV haemorrhoids in favor of using a modified STARR technique.  Patients with grade V internal rectal prolapse/intussusception [16] were excluded. Diagnosis was confirmed by physical examination, defecatory sigmoidoscopy and dynamic defaecography. Patients underwent manometric evaluation and were assessed for colorectal malignancy as considered appropriate.

 

The modified STARR technique

Following an initial EUA and reduction of the prolapse, four radial ‘stay stitches’ are inserted 1cm from the anal canal.  The anal canal is then inverted using a swab, before introducing the lubricated CAD and tying the stay sutures to stabilise it. At this point the STARR technique is modified. The anoscope is inserted into the CAD allowing the surgeon to view the left lateral or 3 o’clock haemorrhoidal mass.  The haemorrhoid is decompressed with the handle of a DeBakey forceps, and a Babcock forceps used to grasp the prolapsing or intusscepting rectum above the anal cushion.   Three full-thickness sutures are placed at the 1, 3 and 5 o’clock positions. The two ends of the 3 o’clock sutures are split and separately combined with the other sutures to give uniform traction on the left lateral prolapse. A lubricated wooden spatula is then inserted into the right lateral window of the CAD and guided 5cm into the lower rectum to protect the rectal wall during the resection. The opened PPH-03 stapler is introduced and the sutures threaded through the openings either side of the stapler housing.  Traction is applied as the stapler is closed and then fired.  It is only after excising the prolapsed haemorrhoid that the extent/grade of the intussusception above can be fully appreciated. The procedure is now repeated for the posterior/right lateral wall, with an additional firing occasionally required to ‘tidy up’ any residual anterior prolapse. Finally the staple line is checked for bleeding and dehiscence.  It is not possible to carry out a STARR resection if there is no intussusception or prolapse.

All patients were reviewed at 2 months, 6 months, and yearly thereafter, during which functional scores were assessed and perineal examinations performed to assess for anatomical recurrence. Functional scores were also compared preoperatively and postoperatively; these included an obstructed defaecation syndrome (ODS) score [17], the Cleveland Clinic Incontinence (CCI) score [18] and QOL Birmingham Bowel and Urinary Symptoms Questionnaire-22 (BBUSQ-22) and Bowel Severity VAS [19] for the impact of bowel and bladder symptoms.   

 

 

Results:

390 patients (245 female, 63%) underwent the STARR procedure for symptomatic ODS and IRP over a 9-year period. The median age of the patients was 53 years (range 19-87.) 

The majority of patients (62%) had grade 4 intussusception.  Of the 245 women who required a STARR, 213 patients (87%) had an associated rectocele.  11 patients (3%) had previously undergone a laparoscopic rectopexy for their symptoms.  As well as ODS, other symptoms included pelvic pain, bleeding, urgency, incomplete emptying and digitation. A detailed breakdown of the grade of IRP and associated symptoms is shown in Table 1. 

Pre-operative mean ODS scores fell from 14.8 (range 0-30), to 2.3 (range 0-18) after surgery.  Mean Wexner faecal incontinence (FI) scores were 3.5 (range 0-14) before treatment, and 0.5 (range 0-12) afterwards.  Patient satisfaction data was available from 364 patients.  Of those questioned, 262 patients (67%) were asymptomatic after surgery.  Overall 314 patients (86.2%) described a significant subjective improvement in their symptoms.    6 patients (1.6%) had no improvement in their symptoms, and one patient felt their symptoms were worse after the procedure.  Quality of Life data was available for 370 patients.  This showed a mean score of 54.7 (range 36-84).  82% (302 of 368 questioned) would ‘definitely’ recommend the surgery.  5.4% of patients would ‘probably’ recommend it.  3.5% of patients would not recommend the procedure.

 

 

 

ODS and Haemorrhoids

In addition to examining patients for intrarectal intussusception, patients were assessed for haemorrhoidal prolapse, and the degree of prolapse recorded using Goligher’s four grades of classification.  There were 307 patients (79%) shown to have clinical evidence of ‘high-grade’ (Grades III or IV) haemorrhoids.  168 (43%) of these were grade III, and 139 (36%) were grade IV.  210 (54%) patients had previously undergone a failed banding of their haemorrhoids.  37 (9%) had undergone an open excision haemorrhoidectomy in the preceding 5 years.  14 patients (4%) had previously undergone a stapled haemorrhoidopexy procedure (PPH). The detailed demographics can be seen in Table 2.  Details of the presenting symptoms in these patients are shown in Table 4.

Table 3 demonstrates the relationship between haemorrhoids and internal rectal prolapse by grade.  High-grade IRP is associated with a high incidence of haemorrhoids.  223 patients (93%) of patients with grade 4 IRP had a degree of haemorrhoidal prolapse (Grade 2-4).  Of these, 76% were grades 3 or 4 haemorrhoids. 

The incidence of haemorrhoids in patients who had already undergone a Milligan-Morgan haemorrhoidectomy, and subsequently went on to require STARR for ODS symptoms, suggests a recurrence of grade III and IV haemorrhoids in 26 of 37 patients (70%) in this group.  Of the 14 patients who had previously undergone a PPH procedure, all but one of the patients (93%) showed a recurrence of grade III or IV haemorrhoids.  A 5 year case series from this unit of 357 patients (135 (38%) of whom had grade IV haemorrhoids) who underwent a PPH up to September 2005, described a recurrence of symptoms in 5 patients (1.4%) at between 14 and 18 months [10].  Three patients were treated with further PPH, and one with banding.  The 13 patients found to have high grade haemorrhoid recurrence and requiring STARR for ODS symptoms would suggest a long term recurrence rate (up to 12 years) of 3.6% of the stapled haemorrhoidopexy (PPH) procedure in our series rising to 8.1% for grade IV haemorrhoids.

Mean pre-op ODS scores in patients with high-grade haemorrhoids was 14.3 (range 0-30).  Mean post-op scores after STARR were 2.2 (range 0-18).  These figures were not dissimilar to the fall in mean ODS scores for all patients (14.8 vs. 2.3).  208 of the 307 patients with high-grade haemorrhoids (68%) were asymptomatic after the procedure.  107 of the 139 patients (77%) with Grade IV haemorrhoids treated with STARR described urgency as a symptom pre-operatively. This fell to 64% post operatively in this group, of the 132 patients for whom data was available. This was for a mean of 6.0 weeks (range 0-60 weeks). In 3.9% of these patients, this was experienced in the morning only.  This contrasted with 61% of the whole series of patients who experienced urgency after STARR. Quality of Life data was available for 134 patients with Grade IV haemorrhoids treated with STARR.  The mean score was 53.6 (range 36-84).  This compared favourably with QoL data for all patients (mean score 54.7).  At 6 months this had fallen to 36.4 (range 27-69, data available for 118 patients) and at one year to 33.2 (range 26-56, data available for 95 patients.)

 Of the high-grade haemorrhoid patients, satisfaction data was available for 287 individuals.  95% of these saw a significant improvement in their symptons of obstructive defaecation.  Four patients (1.4%) with haemorrhoids had no change in their symptoms after STARR.  One patient had worsening of their symptoms.  These results for the subgroup of 307 patients with high-grade haemorrhoids are comparable to those for the total number of patients treated, suggesting similar outcomes whether or not the patient had haemorrhoids.

STARR complications in patients with Grade IV haemorrhoids

Of the 139 patients with Grade IV haemorrhoids treated with STARR, 17 patients (12%) had post-operative bleeding. Of these patients, 3 required a return to theatre, and one required transfusion.  Staple failure occurred in one patient, and one patient had a rectal split.  3 patients (2.1%) subsequently developed a rectal stricture.  These were successfully dilated at six weeks with no sequelae.  One patient developed faecal impaction after the procedure.  Two patients (1.4%) suffered from urinary retention, one of which required a subsequent TURP.  A full list of early complications in these patients is given in Table 5.

 

Discussion:

This series shows STARR to be a safe and effective treatment for symptomatic internal rectal prolapse.  86.2% of patients saw a significant improvement in their symptoms, and complications of the procedure compared favourably with other series.  Subgroup analysis of those patients with high-grade haemorrhoids has shown a significant overlap of patients with haemorrhoids and those with IRP and ODS symptoms.  Among those patients who had had previous surgical treatment for haemorrhoids and had ODS symptoms and IRP, the incidence of recurrence was 70% for Milligan Morgan haemorrhoidectomy, and 93% for PPH.  This suggests a group of patients who have an anatomical problem which conventional haemorrhoidectomy or haemorrhoidopexy cannot adequately address.

Stapled haemorrhoidopexy offers significant advantages in respect to short term outcomes (pain and return to normal function) and patient satisfaction [7].  One area of continuing controversy when comparing PPH and conventional haemorrhoidectomy is the rate of recurrent prolapse.  Whilst some studies [20-23] have reported no difference in the rates of early recurrence within six months between the two techniques, others [9,24-26] have suggested an increased rate of recurrent prolapse following PPH.  The 2007 systematic review by Tjandra et al reported a 5.7% recurrence rate at one year following PPH compared to 1% following excision haemorrhoidectomy.  This was matched by a significant trend toward more recurrent symptoms following PPH (p=0.07) [27].  These latter findings have been confirmed by the 2007 meta-analysis carried out on behalf of NICE which reported a non-significant trend to early recurrent prolapse after PPH (relative risk < one year = 3.2), but a significant increased incidence on long-term follow-up (relative risk > one year = 4.34: odds ratio: 4.34, 95%CI: 1.67, 11.28; p=0.003).  This was mirrored by an increased re-intervention rate for recurrent prolapse (odds ratio: 5.78; 95%CI: 2.0, 23.0, p=0.002) [28].  Our series shows comparable recurrence rates of 1.4% up to 5 years, and 3.6% up to 12 years.  These findings have led some authors to conclude that PPH has limited efficacy for 4th-degree haemorrhoids [12] and as such recommend excision haemorrhoidectomy. 

These results raise questions as to the cause of recurrent prolapse following PPH.  Is it due to poor surgical technique, a limitation of the technique itself, disease severity or simply poor patient selection?  It has been noted that large haemorrhoidal prolapse is commonly accompanied by prolapse of the lower rectal mucosa or an internal intussusception (IRP).  In this series, 79% of patients undergoing STARR for ODS had grade III or IV haemorrhoids.   261 patients (67%) had had previous treatment for haemorrhoids (whether banding, excision haemorrhoidectomy or PPH.)  Our findings suggest that the ‘recurrent haemorrhoids’ really represent continuation of IRP and ODS, the haemorrhoids being secondary to the underlying disease pathology of IRP.  This is supported by the high incidence of high-grade proctological and clinical prolapse associated with grade 3 and 4 haemorrhoids (see Table 3).

Haemorrhoids can present with a variety of symptoms. The Goligher classification can lead to a tendency to neglect the treatment of haemorrhoidal symptoms at the expense of restoring the anatomy.  However, the primary purpose of treatment is to address the presenting symptoms.  Patients with haemorrhoidal disease, and particularly those with ‘high-grade’ disease, should always be questioned for symptoms of ODS.  ‘Constipation’ and straining is often blamed for exacerbation or recurrence of haemorrhoids, but in many patients it is due to ODS.  Patients who do not respond to conservative dietary changes, have evidence of excessive laxative use, straining, repeated visits, digitation or unexplained faecal incontinence may have a functional pelvic floor disorder contributing to their development of haemorrhoids.  It is our opinion that pelvic floor disorders are under-appreciated in this group of patients, and ODS or IRP should be considered and excluded as a primary differential diagnosis in high-grade haemorrhoidal disease.  In the majority of these the diagnosis can be made by a good history and clinical examination.  Examination under anaesthetic with the CAD in situ prior to treatment of haemorrhoids will help to identify the redundant rectal tissue and IRP where this is present, above the prolapsing haemorrhoids.  Treatment may then be tailored (PPH or STARR) provided preoperative informed consent has been sought.

Boccasanta et al randomised 64 patients with IRP but no associated rectocoele or enterocoele to either PPH or STARR [14].  At a mean follow-up of eight months, the incidence of residual disease (rectal prolapse, residual skin tags) in the anopexy (PPH) group was 29% versus 6% in the STARR group (p=0.007). The incidence of complications was low in both groups.  In addition to internal prolapse, the surgeon needs to be aware of the possibility of other coexisting pelvic floor abnormalities, which may adversely impact on outcome. A prospective audit of patients with grade III and IV haemorrhoids, found that 16% had coexisting symptoms of ODS and that over two thirds had abnormalities on defaecating proctography or dynamic MRI [17].  

Clearly not all haemorrhoids are secondary to pelvic floor disorders and ODS, and we present here a select group of patients.  If haemorrhoids and intrarectal intussusception have a common aetiology then it is likely to be multifactorial, involving both patient and behavioural factors. However identifying and excluding those patients with pelvic floor dysfunction from interventions aimed at simply treating haemorrhoids may significantly improve the statistical outcome of such treatments, and protect patients from unnecessary unsuccessful and repeated interventions.

The last decade has seen a renewed interest in the treatment of pelvic floor disorders.  We believe that STARR has an effective role provided that multi-compartment pelvic floor failure has been excluded; selection is the key to success.  We would put forward the concept that IRP and prolapsing haemorrhoids share a common aetiology and that STARR will play a major role in treating these patients in future.

 

References:

Thompson WHF. The nature of haemorrhoids. Br.J.Surg 1975; 62: 542-52.

Haas PA, Fox TA, Jr., Haas GP. The pathogenesis of hemorrhoids. Dis Colon Rectum 1984; 27(7):442-450.

Hardy A, Ansari T, Sibbons PD, Cohen CRG.  Haemorrhoids and collagen types -  a new theory of aetiology.  Brit J Surg (abstract) 2012; 99 (Suppl. 6): 86.

Longo A. Stapled anopexy and stapled haemorrhoidectomy: two opposite concepts and procedures. Dis Colon Rectum 2002; 45: 571-2.

Lindsey I, Nugent K, Dixon T. Pelvic Floor Disorders for the Colorectal Surgeon. 2010 Oxford University Press.

Ommer A, Hinrichs J, Möllnberg H, Marla B, Walz MK. Dis Colon Rectum 2011; 54(5):601-608

Jayne DG, Schwandner O, Stuto A. Stapled transanal rectal resection for obstructed defecation syndrome: one year results of the European STARR Registry. Dis Colon Rectum 2009; 52: 1205-12

Titu LV, Riyad K, Carter H, Dixon AR. Stapled Transanal Rectal Resection for Obstructed Defecation: A Cautionary Tale.  Dis Colon Rectum 2009; 52: 1716-1722

Goede AC, Glancy D, Carter H, Mills A, Mabey K, Dixon AR.  Medium-term results of stapled transanal rectal resection (STARR) for obstructed defaecation and symptomatic rectal-anal intussusception. Colorectal Dis 2011; 13: 1052-1057

 Slawik S, Kenefick N, Greenslade GL, Dixon AR. A prospective evaluation of stapled haemorrhoidopexy/rectal mucosectomy in the management of 3rd and 4th degree haemorrhoids. Colorectal Dis 2007; 9: 352-56.

Collinson R, Cunningham C, D’Costa H, Lindsey I. Rectal intussusception and unexplained faecal incontinence: findings of a proctographic study. Colorectal Dis 2009; 11: 77-83

Ortiz H, Marzo J, Armendariz P. Randomised clinical trial of stapled haemorrhoidectomy versus conventional diathermy haemorrhoiectomy. Br.J.Surg 2001; 89: 1376-81.

Jayne DG, Seow-Choen F.  modified stapled haemorrhoidopexy for the treatment of massive circumfrentially prolapsing piles.  Tech Coloproctol 2002; 6: 191-193.

Bocasanta P, Venturi M, Gaincario R. Stapled transanal rectal resection versus stapled anopexy in the cure of haemorrhoids associated with rectal prolapse.  A randomised controlled trial.  Int.J.Colorectal Dis 2007; 22: 245-51.

Papagrigoriadis S, Vardonikolaki A. Stapled anopexy with double stapling: a safe and efficient treatment of haemorrhoids. Acta Chirurgica Belgica 2006; 106: 717-18.

Collinson R, Cunningham C, D’Costa J, Lindsey I. Rectal intussusception and unexplained faecal incontinence: findings of a proctographic study.  Colorectal Dis 2009; 11(1): 77-83

Riss S, Glöckler M, Abrahamowicz M, Longo A. (2006) The ODS Score - A Novel Instrument To Evaluate Patients With Obstructed Defecation. European Surgery 2006; 7(209).

Jorge JM, Wexner SD. Etiology and management of fecal incontinence. Dis Colon Rectum 1993; 36: 77-97.

Hiller L, Bradshaw HD, Radley SC, Radley S. Criterion validity of the BBUSQ-22: a questionnaire assessing bowel and urinary tract symptoms in women. Int Urogynecol J Pelvic Floor Dysfunct. 2007; 18:1133-7

Rowsell M, Bello M, Hemingway DM. Circumferential mucosectomy (stapled haemorrhoidectomy) versus Milligan-Morgan hemorrhoidectomy:  randomised controlled trial. Lancet 2000; 355: 779-781

Correa-Rovelo JM, Tellez O, Obregon L, Miranda-Gomez A et al. Stapled rectal mucosectomy vs. closed haemorrhoidectomy: a randomised, clinical trial. Dis Colon rectum 2002

Kairaluoma M, Nuorva K, Kellokumpu I. day case stapled (circular) vs. diathermy haemorrhoidectomy: a randomized controlled trial evaluating surgical and functionl outcome. Dis Colon rectum 2003; 46: 93-99.

Chung CC, Cheung HY, Chan ES, Kwok SY et al. Stapled haemorroidopexy vs. Harmonic Scalpel haemorrhoidectomy: a randomised trial. Dis Colon Rectum 2005; 48: 1213-1219.

Ganio E, Altomate DF, Gabrielli F, Milito G et al. Prospective randomised multicentre trial comparing stapled with open hemorrhoidectomy. Br J Surg 2001; 88: 669-674.

Mehigan BJ, Monson JR, Hartley JE. Stapling procedures for haemorrhoids versus Milligan Morgan haemorrhoidectomy: randomised control trial. Lancet 2000; 355: 782-785.

Schwandner O, Brunch HP. Significance of obstructed defecation in haemorrhoid disease: results of a prospective study. Coloproctol 2006; 28: 13-20

Tjandra JJ, Chan MK. Systematic review on the procedure for prolapse and haemorrhoids (stapled hemorrhoidopexy). Dis Colon Rectum 2007; 50(6):878-892

National Institute for Health and Clinical Excellence, Sept 2007. Stapled haemorrhoidopexy for the treatment of haemorrhoids.

 

Tables:

 

Grade IRP

2

3

4

5

Total no. pts

5

107

240

36

Pelvic pain

5 (100%)

96 (90%)

215 (90%)

34 (94%)

Bleeding

5 (100%)

93 (87%)

187 (78%)

29 (81%)

Urgency

4 (80%)

72 (67%)

165 (69%)

30 (83%)

OD

3 (60%)

64 (60%)

151 (62%)

25 (69%)

Digitation

0

23 (21%)

70 (29%)

10 (28%)

Incomplete emptying

5 (100%)

91 (85%)

218 (91%)

32 (89%)

Mean ODS score pre op

7.8

14.0

15.3

14.8

Mean ODS score post op

0.5

1.6

2.7

1.7

Mean Wexner score pre op

1.0

2.7

3.5

6.0

Mean Wexner score post op

0.0

0.4

0.5

0.8

 

Table 1: Degree of IRP and symptoms, including ODS and Wexner scores pre and post op.  Complete data available for 388 patients.

 

 

 

 

Number

Banding

MMH

PPH

Bleeding

pre-op

None / not recorded

16

3

2

0

9

I

3

1

0

0

2

II

64

25

5

1

41

III

168

99

14

2

139

IV

139

82

16

11

124

Total

390

210

37

14

315

 

Table 2:  Incidence of haemorrhoids by grading and previous treatment (MMH = Milligan Morgan haemorrhoidectomy, PPH = Stapled haemorrhoidopexy)

 

 

 

 

 

 

 

 

Internal rectal prolapse grade

 

Haemorrhoid grade

2

3

4

5

Total

4

3

38

85

13

139

3

2

52

97

16

167

2

0

15

41

7

63

1

0

1

2

0

3

0

0

1

15

0

16

Total

5

107

240

36

388

 

Table 3:  Relationship of degree IRP by Grade of Haemorrhoids. Complete data was available for 388 patients.

 

 

 

 

 

 

 

Symptom

Grade III (n=168)

Grade IV (n=139)

Rectal bleeding

83%

89%

Urgency

65%

77%

Obstructive defaecation

64%

53%

Pain

89%

93%

Rectal or vaginal digitation

29%

14%

Incomplete emptying

89%

88%

 

Table 4:  Presenting symptoms of patient with haemorrhoids

 

 

 

 

 

Complication

Number (n=139)

Percentage

Post op bleeding

17

12%

Return to theatre for bleeding

3

2.1%

Blood transfusion

1

0.7%

Rectal split

1

0.7%

Rectal stricture

3

2.1%

Staple failure

1

0.7%

Faecal impaction

1

0.7%

Faecal urgency

85*

64%

Acute urinary retention

2

1.4%

Mortality

0

0

 

Table 5:  Early complications of STARR in patients with Grade IV haemorrhoids

*Data only available for 132 patients


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