title: Tailored therapy for different presentations of chronic pain after stapled hemorrhoidopexy.
abstract: BACKGROUND
  As stapled hemorrhoidopexy (SH) becomes more widely used, we see more patients with chronic postoperative anal pain after this surgery. Its presentation is variable and difficult to treat. The aim of our study was to investigate the impact of chronic anal pain after SH and whether tailored therapy was likely to achieve a favorable outcome.
  
  
  METHODS
  We retrospectively analyzed 31 consecutive patients with chronic anal pain who had undergone SH in other hospitals and were referred to our institutions. Depending on the type of pain, unrelated (at rest) or related to defecation, two groups of patients were identified. Moreover, the mean distance of the staple line from the anal verge was calculated in both groups. Treatments included: topical nifedipine, local anesthetic and steroid infiltration, removal of retained staples, anal dilation, and scar excision with mucosal suturing. A visual analog scale (VAS) was used to compare pain at baseline, postoperatively, and in the follow-up. This mean difference of the VAS score between stages was always used as the main outcome measure, depending on the type of presentation, type of pain, and type of treatment. Treatment response was defined as a 50 % decrease of VAS from baseline.
  
  
  RESULTS
  There were 22 males and 9 females. The overall median age was 43 years (range 21-62 years). On digital examination and proctoscopy, 15 (48 %) patients had inflammatory changes, 19 (61 %) patients had staple retention, 8 (26 %) patients had anorectal stenosis, and 30 (97 %) patients had scar tissue. All patients had one or more of the following treatments listed from the least to most invasive: topical nifedipine in 12 (39 %) patients, anal dilation in 6 (19 %) patients, anesthetic and steroid infiltration in 18 (58 %) patients, removal of staples in 10 (32 %) patients, and scar excision in 18 (58 %) patients. The mean VAS score at baseline was 6.100, ± 1.953 SD, which dropped significantly after treatment to 1.733, ± 1.658 SD (p < 0.001) and remained low at follow-up (1.741 ± SD 1.251; p < 0.743). In patients with pain at rest (n = 20, 65 %), the symptoms improved in 19 (95 %) patients, while the VAS score decreased from 5.552 ± 2.115 SD to 1.457 ± 1.440 SD (95 % CI 3.217-4.964; p < 0.001). In patients with post-evacuation pain (n = 11, 35 %), the symptoms improved in 11 (100 %) patients, while the VAS score decreased from 6.429 ± 1.835 SD to 1.891 ± 1.792 SD (95 % CI 3.784-5.269; p < 0.001). Rating of response based on presentation was 90.0 % (0.9/10) after treatment of staple retention, which led to a significant decrease in the mean VAS score from 6.304 ± 1.845 SD to 1.782 ± 1.731 SD (95 % CI 3.859-5.185; p < 0.001). Anal stenosis was successfully treated in 100.0 % (n = 8/8) of cases with the mean VAS score dropping from 6.500 ± 1.309 SD to 2.125 ± 1.808 SD (95 % CI 2.831-5.919; p < 0.001). Anal inflammation improved in 60.0 % (n = 9/15) of patients and the mean VAS score dropped from 6.006 ± 2.138 SD to 1.542 ± 1.457 SD (95 % CI 3.217-4.964; p < 0.001). The response after scar tissue treatment was 94 % (n = 17/18) of patients with a mean VAS decreasing from 6.117 ± 2.006 SD to 1.712 ± 1.697 SD (95 % CI 3.812-4.974; p < 0.001). Success for topical nifedipine was between 13 and 25 % of patients depending on the clinical presentation. Anal dilation was successful in 75 % of patients, while Anesthetic and steroid infiltration in 23-54 % of patients depending on the clinical presentation. Staple removal was successful in 77 % of patients, and scar excision with mucosal suturing in 94 % of patients.
  
  
  CONCLUSIONS
  Our retrospective study suggests that most patients with chronic anal pain after SH may be cured with treatment by applying a stepwise approach from the least to the most invasive treatment.
authors.affiliation: Asola Surgery Unit, Department of Surgery and Orthopedics, Carlo Poma Hospital, 80th Fanteria Square, 1, 46041, Asola, Mantua, Italy. corrado.asteria@libero.it.
authors.forename: C R
authors.initials: CR
authors.lastname: Asteria
authors.affiliation: Proctology Unit, Department of Visceral Surgery, University Hospital, Geneva, Switzerland.
authors.forename: J
authors.initials: J
authors.lastname: Robert-Yap
authors.affiliation: Proctology Unit, Department of Visceral Surgery, University Hospital, Geneva, Switzerland.
authors.forename: G
authors.initials: G
authors.lastname: Zufferey
authors.affiliation: Department of Human Pathology, Carlo Poma Hospital, Mantua, Italy.
authors.forename: F
authors.initials: F
authors.lastname: Colpani
authors.affiliation: Asola Surgery Unit, Department of Surgery and Orthopedics, Carlo Poma Hospital, 80th Fanteria Square, 1, 46041, Asola, Mantua, Italy.
authors.forename: A
authors.initials: A
authors.lastname: Pascariello
authors.affiliation: Department of Healthcare Medical Management, Biostatistics Service, Carlo Poma Hospital, Mantua, Italy.
authors.forename: G
authors.initials: G
authors.lastname: Lucchini
authors.affiliation: Proctology Unit, Department of Visceral Surgery, University Hospital, Geneva, Switzerland.
authors.forename: B
authors.initials: B
authors.lastname: Roche
mesh_terms: D000328:Adult; D059350:Chronic Pain / Q000209:etiology / Q000628:therapy*; D005260:Female; D005500:Follow-Up Studies; D061865:Hemorrhoidectomy / Q000009:adverse effects* / Q000379:methods; D006484:Hemorrhoids / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010147:Pain Measurement; D010149:Postoperative Pain / Q000209:etiology / Q000628:therapy*; D012189:Retrospective Studies; D013537:Sutures / Q000009:adverse effects*; D016896:Treatment Outcome
keywords: Anal inflammation; Anal stenosis; Chronic postoperative pain; Scar tissue; Staple retention; Stapled hemorrhoidopexy; Suture line; Visual analog scale