title: Stapled hemorrhoidopexy versus Milligan-Morgan hemorrhoidectomy in circumferential third-degree hemorrhoids: long-term results of a randomized controlled trial.
abstract: BACKGROUND
  The literature indicates higher recurrence rates for stapled hemorrhoidopexy than for conventional techniques. This could be due to inappropriate patient selection.
  
  
  OBJECTIVE
  The aim of this study was to evaluate the short- and long-term outcome after stapled hemorrhoidopexy compared with the Milligan-Morgan procedure in a homogeneous patient population with circumferential third-degree hemorrhoids.
  
  
  METHODS
  One hundred thirty patients were enrolled into a randomized controlled study, of which 122 were clinically evaluated at weeks 1, 2, and 4, and thereafter each year for a minimum of 3 years. Patients completed a questionnaire for symptoms, function, and pain. Pain was assessed using a visual analog scale. Recurrences were determined by anoscopy and self-report.
  
  
  METHODS
  The study was performed at the University Hospital Hamburg.
  
  
  METHODS
  Endpoints were pain, recurrence, bleeding, itching/burning, urinary retention, incontinence symptoms, and prolonged rate of wound healing.
  
  
  RESULTS
  The cumulative recurrence rates after 5 years were 18 % (n = 11) in the stapled hemorrhoidopexy group and 23 % (n = 14) in the Milligan-Morgan group (p = 0.65). Patients who underwent stapled hemorrhoidopexy had significantly less postoperative pain with mean VAS scores at week 1: 3.1 vs. 6.2; week 2: 0.5 vs. 3; week 4: 0.05 vs. 0.6 (p < 0.001), and demonstrated less burning/itching sensation 4 weeks after surgery compared with the Milligan-Morgan group (4.9 vs. 19.7 %; p < 0.001). The postoperative bleeding rate was 4.9 % in both groups and the rate of urinary retention did not differ significantly (4.9 % vs. 1.6 %; p = 0.309). Postoperative incontinence symptoms (6.6 % versus 3.3 %; p = 0.40) resolved within the first 6 months.
  
  
  CONCLUSIONS
  Detailed measurement of incontinence was not possible because postoperative symptoms resolved between consultations, and pathological results were examined retrospectively.
  
  
  CONCLUSIONS
  The results show a similar rate of recurrence in the long term and suggest increased patient comfort in the early postoperative course after stapled hemorrhoidopexy. In patients with circumferential third-degree hemorrhoids, stapled hemorrhoidopexy is as effective as the Milligan-Morgan procedure.
authors.affiliation: Department of General, Visceral and Thoracic Surgery, University Medical Center of Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
authors.forename: Jong-Sun
authors.initials: JS
authors.lastname: Kim
authors.forename: Yogesh K
authors.initials: YK
authors.lastname: Vashist
authors.forename: Sabrina
authors.initials: S
authors.lastname: Thieltges
authors.forename: Oliver
authors.initials: O
authors.lastname: Zehler
authors.forename: Karim A
authors.initials: KA
authors.lastname: Gawad
authors.forename: Emre F
authors.initials: EF
authors.lastname: Yekebas
authors.forename: Jakob R
authors.initials: JR
authors.lastname: Izbicki
authors.forename: Asad
authors.initials: A
authors.lastname: Kutup
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D061865:Hemorrhoidectomy / Q000379:methods*; D006484:Hemorrhoids / Q000473:pathology* / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D017792:Surgical Stapling; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult