Opinioni a confronto in coloproctologia LONGO o MILLIGAN-MORGAN? Angelo Stuto S.O.C. Chirugia Generale 2 Az. Osp. “S.M.A.” Pordenone

Hemorrhoid Classification (ASCRS practice parameters) Hemmorhoidal Disease is Caused by Prolapse Hemorrhoid Classification (ASCRS practice parameters)

Conclusion Hemorrhoidal Disease is Caused by Prolapse PPH treats Hemmorhoids by Fixing the Prolapse PPH is Less Painful and Better Respects the Anatomy and Physiology when compared to Hemorrhoidectomy

Hemorrhoidal Treatments Fixes Prolapse Rubber Band Ligation Doppler (?) No Doppler techniques PPH Does not Fix Prolapse Milligan-Morgan Ferguson Parks Laser Cryotherapy ……etc……

Longo primi anni ‘90

PPH – The Past Stapled haemorrhoidopexy (PPH) 2001: 2 small RCTs Longo, A:Treatment of haemorrhoidal disease by reduction of mucosal and haemorrhoidal prolapse with a circular stapling device: a new procedure Proceedings of the 6thWorld Congress of Endoscopic Surgery, Rome 1998 2001: 2 small RCTs Mehigan et al Lancet 2000; 355: 782-5 Roswell et al Lancet 2000; 355: 779-81 Short term benefits Shorter hospital stay Less postoperative pain Earlier return to normal function

PPH – The Past 2000 Disaster! St Marks RCT Case reports Persistent pain and faecal urgency after stapled haemorrhoidectomy Lancet 2000; 356: 730-3 Case reports Life threatening perianal sepsis PPH abandoned in many centers mainly in UK

NICE & PPH NICE review 2006 Independent analysis by Health Economics Unit, University of York Meta-analysis 27 RCTs 2279 patients

Results: operating time 17 trials (89%) reported shorter operating time with PPH Mean op time PPH: 9 – 35.4min Mean op time CH: 11.5 – 53min Significant heterogeneity prevented meta-analysis

Results: hospital stay 14 trials (88%) reported shorter hospital stay with PPH Mean hosp stay PPH: 0.75 – 5.8days Mean hosp stay CH: 0.92 – 11.2days Significant heterogeneity prevented meta-analysis

Results: return to normal activity 14 trials (93%) reported quicker return to normal activity with PPH 10 trials significant Mean time PPH: 6.1 – 23.1days Mean time CH: 9.8 – 53.9days Significant heterogeneity prevented meta-analysis

Results: pain Short-term: less pain following PPH Long-term: few patients; no difference

Results: bleeding Short-term: no difference (OR 0.86; 95% CI: 0.46, 1.61; p=0.63) Long-term: no difference: (OR 1.00; 95% CI: 0.33, 3.01; p=1.00)

Results: complications No difference in short-term or long-term Anal stenosis/stricture Incontinence Faecal urgency Urinary retention Septic complications

PPH & Prolapse Follow-up Outcome OR 95% CI P-value Overall SH worse 5.18 1.73-15.50 0.003 Short-term No diff 3.20 0.71-14.45 0.13 Long-term 4.34 1.67-11.28

PPH: procedure costs PPH device costs offset by reduced length of stay Resource use Costs Unit cost (£) CH SH Theatre time (min) 8.27 29.2 15.5 242 128 Length of Stay (days) 256 2.7 1.4 681 366 Device 420 1 TOTAL PROCEDURE COSTS 923 914 PPH device costs offset by reduced length of stay

NICE Recommendation 2007 “Stapled haemorrhoidopexy, using a circular stapler specifically developed for haemorrhoidopexy, is recommended as an option for people in whom surgical intervention is considered appropriate for the treatment of prolapsed internal haemorrhoids”.

Consideration on the metanalysis results “Low Power”= small pts’ cohort PPH Learning curve vs well known “old” technique Small number of Italian patients How prolapse is evaluated? Is the outcome comparator the same for the 2 techniques?!

PPH vs MMH (metanalisi) PPH vs. MM better for (Pain, recovery, incontinece, stenosis, bleeding etc) PPH vs MM worst for prolapse recurrence but there is no significativity when re-surgery is considered

Recurrent Prolapse following PPH Aetiology ? Role of anal skin tags ? Learning Curve ? Residual prolapsing haemorrhoids PPH resection limited by stapler housing ? De novo prolapse Schwandner et al Coloproctology 2006; 28: 13-20 16% patients with prolapsing haemorrhoids will have symptoms of obstructed defaecation Internal rectal prolapse & rectocele

Distal Rectal Redundancy Rectocele Internal prolapse Haemorrhoids with Internal prolapse

PPH & Obstructed Defaecation All patients presenting with prolapsing piles should be carefully evaluated for coexistent obstructed defaecation Investigation should include defaecatory proctography Consideration given to PPH-STARR (STARR for Haemorrhoids) Combined treatment of piles and internal rectal prolapse

F. Hetzer, A. Senagore in Transanal Stapling approach for anorectal prolapse ed. Springer 2009

SUMMARY Initial concerns regarding PPH have largely been resolved Benefits Shorter hospital stay Less pain Quicker recovery Disadvantage Increased rate of recurrent prolapse Spectrum disease haemorrhoids --- internal rectal prolapse PPH-STARR may be the preferred treatment option