Recurrent hemorrhoidal disease after stapled prolassectomy: hypothesis on predictive factors and surgical management

INTRODUCTION The surgical procedure of stapled haemorrhoidopexy is now considered safe and its safety is improving with experience and technical upgrading. Compared to conventional procedures, stapled haemorrhoidopexy has the advantage - in the short term results - of less postoperative pain but the main disadvantage - in the long term follow-up- of possible recurrent prolapse. This occurs between three months and one year after the operation and should be differentiated -for a more correct evaluation of the results- by the persistent prolapse, that is immediately evident after surgery or in the first two months. Both –persistent and recurrent prolapse- required treatment if symptomatic. The percentage of symptomatic prolapse -persistent and recurrent- after stapled procedures varies widely in the several clinical trials described in the literature, ranging from a minimum of 2% to the worst results of 53.3% (1-9). The unsatisfactory results mainly depend on incorrect indications (IV grade haemorrhoids with predominant external, fibrous component), technical mistakes during surgical procedure and insufficient prolapse correction. Avoiding or minimizing the possibility of a recurrent prolapse should be demanded to a well realized primary operation, calibrated on the effective amount of the prolapse (using single or double stapled technique, instruments with larger case, parachute technique, or with an immediate, intraoperative correction of the persistent prolapse or excision of a residual pile). The aim of this work is to analyze the different features of recurrences after stapled haemorrhoidal operations and the procedures realized to treat them in order to lay down solid and firm starting points to focalize some guidelines of treatment of recurrences after stapled prolapsectomy MATERIAL AND METHODS We performed a retrospective study on 69 patients, affected by recurrent or residual prolapse after a primary operation of stapled haemorrhoidopexy (58 patients treated with a single PPH -PPH- and 11 with a double stapling procedure -DSPPH-) and undergoing reoperative surgery for the treatment of recurrence (Table I). This cohort of patients was recruited between January 2005 and January 2011 in three Italian national reference centers for proctological surgery (Pisa, Rome and Pordenone) and was retrospectively analyzed. RESULTS The symptoms of primary onset had been: haemorrhoidal crisis in 17 patients, bleeding in 5 patients, prolapse in 45 patients and finally both prolapse and bleeding in 2 patients. (Table 2) 58 out of 69 patients had undergone a PPH at the primary operation and 11 out of 69 a DSPPH. In 23 patients (34%) primary surgery had been performed in other Hospitals. Prolapse degree according to Goligher’s classification was: II degree in 15 cases, III degree in 36 cases, IV degree in 18 cases (Table 3). The mean time of recurrence was 18 months (range 2-42 months) in the 58 patients, who had undergone a PPH and 12 months (range 2-42 months) in those who had undergone a D-PPH (Table 4). All operations were performed at least six months after the onset of the recurrence’s symptoms. Only two patients underwent a reoperation after about two months for a haemorrhoidal thrombosis. The clinical onset of recurrence appeared in the form of: haemorrhoidal crisis in 12 patients, bleeding in 8 patients, recurrent prolapse in 29 patients and residual prolapse in 20 patients (Table 5). Intraoperative findings in the 58 patients, who had undergone a previous single PPH, were: 30 recurrent or residual prolapsed haemorrhoids with single or multiple piles- ≤3- (17 residual and 13 recurrent), 4 congested haemorrhoids, 18 mobile prolapse, 6 mobile prolapse associated with thrombosed haemorrhoids. In these cases the operations chosen were: 34 excisional surgery, 12 PPH, 6 DSPPH, 6 PPH plus excisional surgery. Intraoperative findings in the 11 patients, who had undergone a previous DSPPH, were: 6 recurrent or residual prolapsed haemorrhoids with single or multiple piles- ≤3- (3 residual and 3 recurrent), 2 congested haemorrhoids, 2 mobile prolapse, 1 mobile prolapse associated with thrombosed haemorrhoids. In these cases the operations chosen were: 8 excisional surgery, 1 PPH, 1 DSPPH, 1 PPH plus excisional surgery. Table 6 and 7 describe the intraoperative reports after a previous PPH and after a previous DSPPH and the operations applied. The preoperative and postoperative management (use of painkillers drugs, antibiotics and laxatives), the kind of anaesthesia -general or local- of the patients undergoing reoperative surgery for recurring haemorrhoids was similar to that applied in the first operation. The mean operative time was comparable to that of the primary surgery in patients treated with PPH or DSPPH or excisional surgery. The hospital stay and return to full activity were similar to the primary operations. Postoperative complications after a “stapled” operation (PPH, DSPPH) and after a “non stapled”operation are summarised in Table 8. They were comparable to those relative to primary surgery. In the “stapled” group bleeding occurred in 3 patients. In one case the bleeding was controlled by introducing a Foley catheter into the anorectum and by inflating its balloon at 30-40 cm3, one case was coped with a local application of a hemostatic device, one case required a surgical revision under anaesthesia. In the “non stapled” group, instead, bleeding occurred in 1 patient and required a surgical revision. 2 patients in the “stapled” group and 2 patients in the “non stapler” group complained of urgency but this symptoms solved spontaneously one month after operation. Postoperative pain was under control in both group thanks to the use of the routine FANS usually employed. However, there were 2 patients in the “stapled” group and 2 patients in the “non stapler” group, who reported persisting anal pain in the 2 weeks following operation and required further use of painkillers. After this time, the pain symptoms disappeared in these three patients and continued in the other one. The mean follow-up after reoperative surgery resulted in 40 months (range, 23-96) No cases of second recurrence occurred in the treated patients. The outcome assessed on the basis of the clinical examination, as well as at the opinion expressed by the patients was excellent in 34 patients, good in 23 patients, sufficient in 8 patients, poor in 4 patients because two considered their symptoms (bleeding and congested haemorrhoids) unchanged, one reported a worsening of constipation and another complained of persistent pain. DISCUSSION The presence of a residual or recurrent prolapse can be derived or from an incorrect indication to surgery or from an insufficient resective approach. Alternatively it may be due to an operation, which had been previously carried out incorrectly with an insufficient pull of the prolapsed tissue in the operative case. In case of recurrence, symptoms guide to the decision of a reoperation and the surgical technique is determined according to the intraoperative report, that in almost equal percentage is divided between the mobility of the prolapse and the presence of recurrent and/or residual haemorrhoidal prolapsed piles. In the case of a mobile prolapse the choice was a transrectal resection with stapler (PPH or DSPPH, depending on the amount of the prolapse that should be resected). On the contrary, in the case of a fixed prolapse or single or multiple piles -≤3_, the choice should be a traditional surgery (Milligan Morgan, whatever performed). In case of multiple piles ≥3 the choice is a transrectal resection with stapler (PPH or DSPPH, depending on the amount of the prolapse that should be resected). A PPH combined with Milligan Morgan Haemorrhoidectomy is applied in case of a mobile prolapse with some residual pile. CONCLUSIONS Avoiding or minimizing the possibility of a recurrent prolapse should be demanded to a well realized primary operation, calibrated on the effective amount of the prolapse. A complete clinical study with a correct evaluation of the symptoms and a careful intraoperative assessment of the recurrence’s features are of primary importance for the choice of the technique to be applied. Re-excisional surgery but also a re-stapled procedure can be safely and successfully realized with the same operating methods of a primary operation, with no more complications or difficulties.