Background: stapled haemorrhoidopexy is widely accepted to treat haemorrhoids, but damage to the sphincter mechanism, bleeding, and life threatening sepsis have been reported. In this prospective audit we correlated clinical outcome with pathological findings.
Methods: from 1/03 to 11/06, 86 symptomatic patients underwent haemorrhoidopexy. Preoperative continence score was performed in all patients. Anorectal manometry and/or ultrasonography (US) were performed if required. Macroscopic appearance of the resected specimen including shape, size and depth were recorded. Microscopically, the presence of columnar, transitional, and squamous epithelium as well as involvement of circular/longitudinal smooth muscle were assessed. Features of mucosal prolapse such as muscularization of the lamina propria, thickening/disruption of the muscularis mucosa, diamond shaped crypts, surface hyperplasia and thrombosed vessels were also assessed. Patients were seen 1 week after surgery and 1, 3, 6 and 12 months thereafter. Clinical outcome was assessed by a validated questionnaire on postoperative symptoms/satisfaction supplemented by the Wexner incontinence score. Patients with delayed healing, chronic pain or complicated outcome underwent manometry and/or US. Data is analysed using Fisher exact and Mann-Whitney tests.
Results: perioperative morbidity rate was 5.8% (bleeding and urinary retention). Postoperative pain, secretion and bleeding durations were 15.1+/-17.1 days, 5.4+/-9.3 days and 6.4+/-8.5 days. Patient's return to work averaged 17.3+/-10.8 days. Seven patients (8.1%) experienced significant longer pain duration (>30 days). Fissure, skin tags and anal stricture were observed in 22% of the patients. Two patients experienced urgency and 3 recurrence. Pathology revealed that 100% of the specimens contained columnar mucosa: 59.3% contained only columnar epithelium, 33.7% contained columnar and transitional epithelium, while 7% contained columnar, anal transitional and stratified squamous epithelium. Smooth muscle was observed in 57% of the specimens. Circular smooth muscle was present in 39.5%, while longitudinal in 17.4%. All samples contained at least one feature of prolapse. Correlation between pathology and clinical outcome showed that pain was significantly increased if squamous and transitional epithelium were present in the specimen. No correlation or differences were observed if smooth muscle was present.
Conclusions: this study shows that haemorrhoidopexy is safe and effective. Damage to the sphincter mechanism, full thickness rectal resection, bleeding and long term results in terms of recurrence and anorectal function need more evaluation.