title: Stapled hemorrhoidectomy--cost and effectiveness. Randomized, controlled trial including incontinence scoring, anorectal manometry, and endoanal ultrasound assessments at up to three months.
abstract: OBJECTIVE
  Stapled hemorrhoidectomy is performed without leaving painful perianal wounds. The aim of this study was to assess any benefits, compared with a conventional open diathermy technique.
  
  
  METHODS
  A total of 119 consecutive patients with prolapsed irreducible hemorrhoids were randomly assigned (conventional open diathermy technique = 62; stapled hemorrhoidectomy = 57). Preoperative fecal incontinence scoring, anorectal manometry, and endoanal ultrasound were performed. Postoperatively, these were repeated at up to three months with pain scores, analgesic requirements, quality of life assessment, and total related medical costs.
  
  
  RESULTS
  Conventional open diathermy technique was quicker to perform (mean, 11.4 (standard error of the mean, 0.9) vs. 17.6 (3.1) minutes). Hospitalization was similar, but conventional open diathermy technique patients felt more pain during defecation (5.1 (0.4) vs. 2.6 (0.4); P < 0.005) at two weeks, and analgesic requirements were more for up to six weeks (P < 0.05). Up to the latter, 85.5 percent conventional open diathermy technique wounds remained unhealed, with more bleeding (33 (53.2 percent) vs. 19 (33.3 percent); P < 0.05) and pruritus (27 (43.5 percent) vs. 9 (15.8 percent); P < 0.05). Total complication rates were similar (conventional open diathermy technique 16 (25.8 percent) vs. stapled hemorrhoidectomy 10 (17.5 percent)), including mild strictures and bleeding in both groups. Minor incontinence occurred postoperatively in two conventional open diathermy technique and two stapled hemorrhoidectomy patients at six weeks. Endoanal ultrasound internal anal sphincter defects were found in the incontinent conventional open diathermy technique patients, but were asymptomatic in another one conventional open diathermy technique and one stapled hemorrhoidectomy. Only one patient (conventional open diathermy technique with internal sphincter defect) remained incontinent at three months. Changes between preoperative and postoperative anorectal manometry were similar in the two groups. Patients' satisfaction scores and quality of life assessments were also similar. Conventional open diathermy technique patients resumed work later (mean 22.9 (1.8) vs. 17.1 (1.9) days; P < 0.05), but the total costs incurred were less ($921.17 (16.85) vs. $1,283.09 (31.59); P < 0.005).
  
  
  CONCLUSIONS
  Stapled hemorrhoidectomy is a safe and effective option in treating irreducible prolapsed piles. It is more expensive but less painful, with less time needed off work. Nonetheless, long-term results are still awaited.
authors.affiliation: Department of Colorectal Surgery, Singapore General Hospital, Singapore.
authors.forename: Y H
authors.initials: YH
authors.lastname: Ho
authors.forename: W K
authors.initials: WK
authors.lastname: Cheong
authors.forename: C
authors.initials: C
authors.lastname: Tsang
authors.forename: J
authors.initials: J
authors.lastname: Ho
authors.forename: K W
authors.initials: KW
authors.lastname: Eu
authors.forename: C L
authors.initials: CL
authors.lastname: Tang
authors.forename: F
authors.initials: F
authors.lastname: Seow-Choen
mesh_terms: D000328:Adult; D000368:Aged; D003113:Colonoscopy; D003362:Cost-Benefit Analysis; D013505:Digestive System Surgical Procedures / Q000009:adverse effects / Q000191:economics* / Q000379:methods*; D019160:Endosonography; D005242:Fecal Incontinence / Q000175:diagnosis* / Q000209:etiology; D005260:Female; D006484:Hemorrhoids / Q000175:diagnosis / Q000601:surgery*; D006801:Humans; D007902:Length of Stay / Q000191:economics; D016015:Logistic Models; D008297:Male; D008365:Manometry; D008875:Middle Aged; D008991:Monitoring, Physiologic / Q000379:methods; D010149:Postoperative Pain / Q000175:diagnosis* / Q000000981:diagnostic imaging; D012720:Severity of Illness Index; D012846:Singapore; D018709:Statistics, Nonparametric; D013525:Surgical Instruments; D016896:Treatment Outcome