title: Persistent anal and pelvic floor pain after PPH and STARR: surgical management of the fixed scar staple line.
abstract: BACKGROUND
  Persistent anal pain (PAP) after stapled procedures, be it hemorrhoidopexy (PPH) or stapled transanal rectal resection (STARR) may be hardly resolved by medical therapy. The typical objective finding in these patients is the staple line characterized by fixed scar to underlying layers.
  
  
  METHODS
  A total of 21 consecutive patients were operated for PAP after stapled procedure. The scarred staple line was excised and detached from layers below, the mucosal continuity reconstructed by single stitches. From January 2003 to December 2013 1500 patients underwent stapled procedure. Of these patients treated in our unit, 9 (0.6 %) were operated for chronic anal pain and 12 were referred to our center from other hospitals.
  
  
  RESULTS
  Fifteen (71.4 %) patients resolved and do not take any drugs for pain; an overall of 85.7 % (18/21) improved their clinical status. Mean time between the beginning of symptoms and the operation was 4.27 months (range 1-18 months). We divided the patients into three groups: before 3 months, between 3 and 6 months and after 6 months from the beginning of symptoms to the operation. The best results were in the first group with 100 % pain relief and satisfactory functional results.
  
  
  CONCLUSIONS
  The relief of PAP after stapled procedure, in which we recognize a scarred and fixed staple line, depends by the early recognition of this typical finding. The authors suggest the surgical treatment not later than 3-6 months after the onset of symptoms to achieve the best results.
authors.affiliation: Proctological and perineal Surgical Unit, Department of Gastroenterology, Cisanello University Hospital, Pisa, Italy.
authors.forename: Claudia
authors.initials: C
authors.lastname: Menconi
authors.affiliation: Proctological and perineal Surgical Unit, Department of Gastroenterology, Cisanello University Hospital, Pisa, Italy.
authors.forename: Bernardina
authors.initials: B
authors.lastname: Fabiani
authors.affiliation: Proctological and perineal Surgical Unit, Department of Gastroenterology, Cisanello University Hospital, Pisa, Italy.
authors.forename: Iacopo
authors.initials: I
authors.lastname: Giani
authors.affiliation: General, Emergency and Mininvasive Surgery I, Careggi University Hospital, largo Brambilla 3, 50134, Firenze, Italy. jamjac64@hotmail.com.
authors.forename: Jacopo
authors.initials: J
authors.lastname: Martellucci
authors.affiliation: Proctological and perineal Surgical Unit, Department of Gastroenterology, Cisanello University Hospital, Pisa, Italy.
authors.forename: Gianluca
authors.initials: G
authors.lastname: Toniolo
authors.affiliation: Proctological and perineal Surgical Unit, Department of Gastroenterology, Cisanello University Hospital, Pisa, Italy.
authors.forename: Gabriele
authors.initials: G
authors.lastname: Naldini
mesh_terms: D000328:Adult; D000368:Aged; D001003:Anal Canal / Q000601:surgery*; D002921:Cicatrix / Q000601:surgery*; D013505:Digestive System Surgical Procedures / Q000009:adverse effects*; D005260:Female; D006484:Hemorrhoids / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010149:Postoperative Pain / Q000209:etiology*; D017773:Pelvic Floor / Q000601:surgery*; D017699:Pelvic Pain / Q000209:etiology*; D012007:Rectum / Q000601:surgery; D017792:Surgical Stapling / Q000009:adverse effects*; D013537:Sutures
keywords: Persistent anal perineal pain; Stapled hemorrhoidopexy; Stapled transanal rectal resection