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

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

4. 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

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

6. Longo primi anni ‘90

8. 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:
Short term benefits
Shorter hospital stay
Less postoperative pain
Earlier return to normal function

9. 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

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

11. 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

12. 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

13. 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

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

15. 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)

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

17. PPH & Prolapse Follow-up Outcome OR 95% CI P-value Overall SH worse
5.18
0.003
Short-term
No diff
3.20
0.13
Long-term
4.34

18. 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

19. 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”.

20. 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?!

21. 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

22. 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

23. Distal Rectal Redundancy
Rectocele
Internal prolapse
Haemorrhoids with
Internal prolapse

24. 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

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

26. 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