The surgical treatment of hemorrhoids with a circular stapler (stapled hemorrhoidopexy, CS) traces back to Koblandin and Shalkov (surgeons, Kazakhstan), who first reported it in 1981 [1]. Longo from Palermo adopted this method in 1992 and contributed to its widespread use, including in Germany in 1998. Longo did not publish his own works on this topic; his contributions were limited to letters to the editor [2, 3].
Initially, the effect of the CS technique was explained by the circular interruption of arterial inflow to the hemorrhoidal plexus [4, 5, 6]. However, studies by Kolbert and Aigner demonstrated that the effect of a hemorrhoid stapler operation is more due to improved venous drainage of the hemorrhoidal plexus through the resection of the mucosal cuff rather than an interruption of arterial inflow [7, 8].
Since 1998/99, publications of case series on the CS method for hemorrhoidal disease have increased sharply. Due to the heterogeneous patient population with different stages of hemorrhoidal disease, the recurrence rate in these studies ranged from 0 to 58% [9]. The higher the stage, the greater the risk of recurrence or reoperation seemed to be [9, 10, 11]. The complication rate also varied greatly, ranging from 0 to 63%, with information on continence disorders mostly missing [12, 13].
Indications
The hemorrhoidopexy using the CS technique is indicated for reducible circular hemorrhoids of grade 3. In grade 4 hemorrhoids, there is a fixed, non-reducible prolapse, which postoperatively leads to traction tension of the stapler suture, resulting in dehiscence and thus a recurrent prolapse.
Both non-comparative and randomized studies included grade 4 hemorrhoids, which was reflected in meta-analyses. The recurrence rate after CS is significantly higher compared to hemorrhoidectomy according to Milligan-Morgan, especially in grades 3 and 4 hemorrhoids. Other authors report a higher recurrence rate in grade 4 hemorrhoids compared to grade 3 hemorrhoids. Zacharakis describes a recurrence rate of 59% and a reoperation rate of 43% after CS [9, 11, 14]. Therefore, the reducible circular prolapse is the ideal indication for the CS procedure.
In exceptional cases (circular finding, frustrating conservative therapy), it is also possible to operate on grade 2 hemorrhoids using the CS procedure. In cases of extensive hemorrhoidal prolapse, some Italian authors perform the CS procedure with two stapling devices [15 - 18]. For this purpose, so-called "high-volume" stapling devices have been developed, which can accommodate a larger resectate in the housing.
The evidence-based recommendations of the German S3 guideline for the treatment of hemorrhoidal disease are therefore:
- The stapler procedure should be offered as a procedure for circular third-degree hemorrhoidal prolapse [19 - 22].
- In grade 4 hemorrhoids, the stapler procedure should not be used, as the recurrence rate is higher compared to conventional surgical techniques [9, 11, 14, 23 - 31].
Postoperative Pain
Comparative studies have found that the CS technique causes less postoperative pain than the Milligan-Morgan and Ferguson techniques. In a randomized study with 95 patients, Basdanis reported significantly less pain after hemorrhoidectomy using Ligasure (LS) compared to the CS technique [32]. In Kraemer's study, no difference was found between LS and CS in terms of postoperative pain, as well as in two meta-analyses [33, 34, 35].
The results regarding postoperative pain in comparison to the CS and Harmonic Scalpel (HS) technique are not clear. In two randomized studies, postoperative pain after CS was significantly lower compared to HS, while Leventoglu found no difference in pain [36, 37]. Two studies reported on the difference between hemorrhoidal artery ligation (HAL), recto-anal repair (RAR), and CS. In one study, pain after HAL and RAR was not significantly lower than after CS, while this difference was significant in the second study [38, 39]. The network analysis by Simillis found no differences in postoperative pain between CS and LS, HS, HAL, and RAR [40]. The only difference was between CS and MM/FG (less pain after CS).
Urinary Retention
One of the most common complications after hemorrhoid surgery is urinary retention. Three reviews found that the MM/FG methods showed a lower, non-significant urinary retention rate compared to CS [36, 40 - 44]. Only in one study was a significantly higher urinary retention rate after CS found compared to MM [44]. The comparison of LS and HS with CS showed no difference in the frequency of postoperative urinary retention [36, 37]. The network analysis by Simillis between CS and MM/FG/LS/HS/HAL/RAR also found no difference regarding urinary retention [40].
Bleeding
Several reviews found a lower, non-significant number of postoperative bleedings in the comparison of CS with MM and FG [40, 41, 45, 46]. The comparison to LS showed no difference in bleeding rate in two meta-analyses [34, 35]. This also applies to the comparison with HS in two randomized studies [36, 37]. In Verre's study, there were postoperative bleedings only in patients after CS, which were not significant, in contrast to HAL and RAR [39]. The network analysis by Simillis could not demonstrate a difference between CS and MM regarding postoperative bleedings. In contrast to HAL/RAR, CS showed a higher bleeding rate here [40].
Re-Operations
Three studies showed a significantly higher reoperation rate after CS compared to MM and FG [29, 47, 48]. In 4 other studies, this was not significant [21, 30, 49, 50]. In the meta-analyses by Tjandra et al., no significant difference in reoperation rate between CS and MM and FG was found [40, 51, 52, 53]. According to Laughlan, the reoperation rate after CS was significantly higher compared to MM, while reinterventions after FG were only slightly increased [46]. In comparison to HAL and RAR, Beliard found -not significantly- fewer reinterventions after HAL and RAR compared to CS, while Simillis found no significant difference in comparison to CS, LS, MM, and FG [38, 40]. The reoperations after CS were necessary in Brusciano due to persistent pain, bleeding, and remaining staples [irritation, bleeding) [54]. In Sileri, 16 patients had to be reoperated due to recurrence, urge incontinence, frequent bowel movements, severe persistent pain, colicky abdominal pain, fissure, and stenosis [55].
Strictures/Stenoses
As a result of the circular mucosal resection and anastomosis by the CS technique, circular stenoses and strictures can develop [56 -68]. In a digital rectal examination, most stenoses or strictures could be relatively easily dilated; in rare cases, a revision under anesthesia is required.
Recurrence
The term recurrence is defined differently in studies, including recurrent prolapse, recurrent symptoms, and reoperations. In most studies of the CS group, recurrence rates were higher in the CS group than in MM and FG [6, 21, 24, 29, 30, 48, 70 - 82]. The recurrence rate after CS was not significantly lower than after MM and FG in some studies [68, 83 - 88]. In contrast, various reviews and meta-analyses indicate a significantly higher recurrence rate after CS compared to MM and FG [46, 52, 53, 89 - 95]. However, stages 2, 3, and 4 were included in almost all meta-analyses. In Beliard's study, there were -not significantly- fewer recurrence rates after CS compared to HAL/RAR [38]. In the network analysis by Simillis, a significantly higher recurrence rate after CS compared to MM, FG, and LS is indicated [40].
Incontinence
After CS, urge incontinence can occur in some cases, which is often temporary. It was found in some studies that smooth muscle was detectable in the resectate in these cases. In a comparative study, smaller damages in the sphincter area (fragmented M. sphincter ani int.) were detected endosonographically when working with the 37 mm anoscope included in the stapler set [96]. In Schmidt's study, the risk of urge incontinence was twice as high in women if muscle tissue was detected in the resectate, while it was not increased in men [97]. In terms of continence scores and manometry values pre- and postoperatively, no significant differences were found between CS and MM in studies [67, 98].
Hasse found significantly higher incontinence scores after CS compared to Parks (PA), although significantly higher resting and voluntary pressures were measured in the CS group [73]. Wilson found through manometric studies that there were no significant differences between CS and MM [44]. Two reviews reported a non-significantly lower stapler incontinence rate, while one review reported a non-significantly higher incontinence rate [46, 91, 99]. Two meta-analyses found no difference in terms of continence function in the comparison of CS and LS [92, 93]. Also, in the comparison of CS and HS as well as CS and HAL/RAR, no differences were found [36, 37, 38]. In the network analysis by Simillis, no significant differences in terms of continence problems were found between the different methods (CS, MM/FG/LS/HS and HAL/RAR) [40].
The German S3 guideline provides the following evidence-based statement on complications after CS [40, 46, 53, 91, 92, 93].
- Compared to conventional operations, the complication rates for urinary retention, postoperative bleeding, and revision surgeries as well as postoperative incontinence are not higher with the CS technique.
- Pain is only lower in the early postoperative phase after CS compared to conventional procedures.
- The recurrence rate is higher after CS compared to conventional procedures.