Stapled transanal rectal resection versus stapled anopexy in the cure of hemorrhoids associated with rectal prolapse. A randomized controlled trial |
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Authors: | Paolo Boccasanta Marco Venturi Giancarlo Roviaro |
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Institution: | (1) Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, IRCCS Foundation, Milan, 1st Department of General Surgery, University of Milan, Via F. Sforza 35, 20122 Milan, Italy;(2) Via G.B. Morgagni 39, 20129 Milan, Italy |
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Abstract: | Purpose A remarkable incidence of failures after stapled axopexy (SA) for hemorrhoids has been recently reported by several papers,
with an incomplete resection of the prolapsed tissue, due to the limited volume of the stapler casing as possible cause. The
stapled transanal rectal resection (STARR) was demonstrated to successfully cure the association of rectal prolapse and rectocele
by using two staplers. The aim of this randomized study was to evaluate the incidence of residual disease after SA and STARR
in patients affected by prolapsed hemorrhoids associated with rectal prolapse.
Methods Sixty-eight patients were selected on the basis of validated constipation and continence scorings, clinical examination, colonoscopy,
anorectal manometry, and defecography and randomized: 34 underwent a SA and 34 a STARR operation. The operated patients were
followed-up with clinical examination, visual analog scale for postoperative pain, a satisfaction index, and defecography.
Results At a mean follow-up of 8.1 +/− 2.0 and 7.9 +/− 1.8 months for the SA and STARR groups, respectively, the incidence of residual
disease was significantly higher in the first group (29.4 vs 5.9 in the STARR group, p = 0.007), while a significantly lower incidence of residual skin-tags was found after STARR (23.5% vs 58.8 after SA, p = 0.03). All patients with residual disease showed prolapsed tissue over half the length of the anal dilator at the time
of the operation. Operative time and incidence of transient fecal urgency were significantly higher in the STARR group (with
p = 0.001 and 0.08, respectively), while SA was followed by a significantly higher incidence of poor results at the overall
patient satisfaction index (p = 0.04). No significant differences were found in hospital stay, operative complications, postoperative pain, time to return
to normal activity, continence, and constipation scores. All the defecographic parameters significantly improved after STARR,
while SA was followed only by a trend to a reduction of rectal prolapse.
Conclusions STARR provides a more complete resection of the prolapsed tissue than SA in patients with association of prolapsed hemorrhoids
and rectal prolapse with equal morbidity and significantly lower incidence of residual disease and skin-tags. The anal dilator
can be used for selecting the surgical technique. |
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Keywords: | STARR vs stapled anopexy Hemorrhoids Rectal prolapse |
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