Picture the scene: June 18, 1815,
the field of Waterloo. As Napoleon's Grande Armée
breaks on the Anglo-German lines, it seems strangely
directionless. Where is the famous general who led the
French to so many victories? Sitting on a bucket a mile
behind the action, writhing in pain.
Hemorrhoids don't cost most a military
empire, but they do afflict about half the population
at some point. The most painful grade three and four
hemorrhoids require invasive treatment, but given their
prevalence, there is constant pressure to find less
dramatic surgical approaches than the gold standard
of excision.
Two such approaches have been rubber-band
ligation and circular stapling (stapled hemorrhoidopexy),
both of which work by cutting blood supply to the hemorrhoid
rather than removing it. Early studies, mostly with
short follow-up, found evidence of lesser morbidity
and pain following both of these procedures.
Stapling has gained ground since
its appearance in the late 1990s, but not all colon
and rectal surgeons are convinced. These are the doctors
who must intervene when stapling doesn't work, and anecdotal
evidence is growing that they frequently must re-operate
on stapled patients. A 2004 Italian study in the journal
Diseases of the Colon and Rectum listed an alarming
number of cases where reintervention was required.
This suspicion is backed up by
a new study from researchers at the University of Western
Ontario. Published in the Cochrane Library, their study
finds that hemorrhoid recurrence was about four times
as common in stapled patients as in excision patients.
Led by Dr Shiva Jayaraman, the
team reviewed seven studies involving 537 patients of
whom half had undergone stapling and half excision.
Out of 269 stapling patients, 23 suffered recurrences,
compared with just four among 268 patients in the excision
group. The risk of prolapse among stapled patients was
also found to be elevated threefold, both in the short
and long term.
"If hemorrhoid recurrence and prolapse
are considered the most important clinical outcomes,"
conclude the authors, "then conventional excisional
hemorrhoidectomy remains the 'gold standard' treatment
for hemorrhoids."
Among the majority of patients
who see no recurrence, stapling did seem to be less
of an inconvenience. The stapled group showed less pain,
pruritis ani and fecal urgency, though none of these
trends reached statistical significance.
This study mirrors the findings
of another Cochrane Collaboration analysis published
last year, which compared excision to rubber band ligation
and found it superior over the long term.
But ultimately, the authors say,
their study does not discredit stapling. Both techniques
are very safe. "Really what we're suggesting," says
Dr Jayaraman by telephone, "is that patients should
be informed of the trade-off between recurrence risk
and convenience. The feeling among many specialists
nowadays is that grade four hemorrhoids might be better
treated with excision."
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