A comparative study on efficacy and safety of modified partial stapled hemorrhoidopexy versus conventional hemorrhoidectomy: a prospective randomized controlled trial

Tae Gyu Kim; Chul Seung Lee; Dong Geun Lee; Choon Sik Chung; Seung Han Kim; Sang Hwa Yu; Jeong Eun Lee; Gwan Cheol Lee; Dong Woo Kang; Jeong Sub Kim; Gyu Young Jeong

doi:10.3393/ac.2024.00535.0076

Articles

Page Path: HOME > Ann Coloproctol > Volume 41(2); 2025 > Article

Original Article Anorectal benign disease A comparative study on efficacy and safety of modified partial stapled hemorrhoidopexy versus conventional hemorrhoidectomy: a prospective randomized controlled trial: Tae Gyu Kim, Chul Seung Lee, Dong Geun Lee, Choon Sik Chung, Seung Han Kim, Sang Hwa Yu, Jeong Eun Lee, Gwan Cheol Lee, Dong Woo Kang, Jeong Sub Kim, Gyu Young Jeong; Annals of Coloproctology 2025;41(2):145-153.
DOI: https://doi.org/10.3393/ac.2024.00535.0076
Published online: April 28, 2025

Division of Colorectal Surgery, Department of Surgery, Hansol Hospital, Seoul, Korea

Correspondence to: Gyu Young Jeong, MD, PhD Division of Colorectal Surgery, Department of Surgery, Hansol Hospital, 445 Songpa-daero, Songpa-gu, Seoul 05616, Korea Email: jeong4847@gmail.com

• Received: August 13, 2024 • Revised: November 24, 2024 • Accepted: November 24, 2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

prev next

534 Views
44 Download

Full Article

Download PDF

Abstract
INTRODUCTION
METHODS
RESULTS
DISCUSSION
ARTICLE INFORMATION
Supplementary materials
REFERENCES

Abstract

Purpose
The long-term outcomes and efficacy of partial stapled hemorrhoidopexy (PSH) compared with those of conventional hemorrhoidectomy (CH) are not fully understood. This study aimed to introduce a modified PSH (mPSH) and compare its clinical efficacy and safety with those of CH.
Methods
A prospective randomized controlled trial was conducted. This study was performed at a single hospital and involved 6 colorectal surgeons. In total, 110 patients were enrolled between July 2019 and September 2020. Patients were randomly assigned to undergo either mPSH group (n=55) or CH group (n=55). The primary outcome was to compare postoperative average pain and postoperative peak pain using visual analog scale score between the 2 groups.
Results
The required duration of analgesia was shorter in the mPSH group than in the CH group, although the difference was not statistically significant (P=0.096). However, the laxative requirement duration (P<0.010), return to work (P<0.010), satisfaction score (P<0.010), and Vaizey score (P=0.014) were significantly better in the mPSH group. The average and peak postoperative pain scores were significantly lower in the mPSH group during the 15 days after surgery (P<0.001). The overall complication rate in both groups was 9.1%, with no significant difference between the groups (P=0.867).
Conclusion
The mPSH group demonstrated better improvement in symptoms, lower pain scores, and greater patient early satisfaction after surgery than the CH group. Therefore, this surgical technique appears to be a safe and effective alternative for CH.
Keywords: Hemorrhoids; Partial stapled hemorrhoidopexy; Quality of life; Prospective randomized controlled trial

INTRODUCTION

Hemorrhoidal disease is a common pathological condition with an estimated prevalence rate of 14.4% in Korea [1]. Approximately 1 in every 5 patients with hemorrhoids requires invasive surgery [2, 3]. Over the years, numerous surgical methods have been developed for treating hemorrhoids [4–8]. The circular stapled hemorrhoidopexy (CSH) technique was first introduced by Longo in 1998 for the management of symptomatic hemorrhoidal prolapse [9]. Compared to conventional hemorrhoidectomy (CH), CSH procedures result in less postoperative pain. However, rare but significant complications, such as prolonged discomfort, stricture, or rectovaginal fistula, have been reported in association with CSH [10–15].

In response to these issues, aiming to reduce associated complications, the partially stapled hemorrhoidopexy (PSH) technique was developed and subsequently implemented. To date, no large-scale randomized controlled trials (RCTs) or meta-analyses have compared the complications associated with PSH and CSH. However, some studies have reported that PSH compared to CSH better decreases the probability of urgency, chronic pain, and stricture [16–19]. Our surgeons have been using a partially mPSH method since 2019 to reduce the incidence of the aforementioned complications. The purpose of this study was to compare the clinical efficacy and complication rates associated with modified PSH (mPSH) and CH.

METHODS

Ethics statement

This prospective RCT was approved by the Clinical Research Information Service (CRIS; No. KCT0004430). This study was also approved by the Institutional Review Board of Hansol Hospital (No. HSHIRB2019002). Relevant ethical guidelines were followed and informed consent was obtained from all participants for surgery and permission to use data for publication. The personal information of the study participants and the information obtained through telephone follow-up only include the date of birth, used for identification verification. This information was retained for 3 years after the completion of the study and then disposed of. This study followed the CONSORT (Consolidated Standards of Reporting Trials) reporting guideline (Supplementary Table 1).

Study design and population

This prospective RCT included 110 patients recruited from July 2019 to September 2020, with 55 patients allocated to each group. Patients presenting symptomatic hemorrhoids, including grades III, IV, and mixed hemorrhoids, were eligible for enrollment.

The study excluded patients who met any of the following criteria: (1) any mental or neurological disease; (2) concurrent anorectal disease; (3) history of pelvic radiotherapy; (4) American Society of Anesthesiologists (ASA) physical status IV and V; (5) history of allergy to nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, or narcotics; (6) coagulation disorders; (7) pregnancy or lactation; (8) history of use of other surgical or nonsurgical methods; and (9) refusal to provide written consent (Fig. 1).

The patients were randomly assigned to either the mPSH group (n=55) or the CH group (n=55). Randomization was conducted using computer-generated random numbers to divide the treatment assignments into groups of 10 in a 1:1 ratio to ensure even distribution. The resulting random assignments were then stored using sealed, opaque envelopes. This procedure was carried out by research nurses who were not involved in patient care to maintain blinding in the randomization process. When a patient who consented to the study arrived in the holding area before surgery, the attending surgeon opened the top envelope and was able to confirm the surgical method only after that. However, during hospitalization and postoperative outpatient visits, surgeons could identify the surgical method used for the patient. Patient demographics, perioperative data, postoperative pain, patient's subjective postoperative satisfaction, quality of life, hemorrhoidal symptom score (Table 1), incontinence, and long-term outcomes were evaluated. Postoperative pain was measured daily from day 1 to day 15 using visual analog scale (VAS), with an additional measurement on day 30, while patients self-reported their average and peak pain on provided questionnaires. The quality of life was assessed using the 12-Item Short Form Health Survey (Physical Health Component Summary [PCS-12] and Mental Health Component Summary [MCS-12]). Vaizey scores, which measure fecal incontinence symptoms, were also assessed. We trained the patients to fill out the questionnaire items based on when they returned to their daily lives and when they were working. The questionnaires and self-reported pain score were then collected during the outpatient visit on postoperative day 30. Although participants consented, if it was deemed difficult to derive results due to lack of cooperation before, during, or after surgery, the researchers decided to restrict the participant's involvement in the study. However, no patients were excluded from the study for these reasons. At a mean follow-up duration of 18 months after surgery, telephone follow-up interviews were conducted to assess patient satisfaction with the surgery and check for the presence of prolapse. In the mPSH group, 41 patients answered the phone, while in the CH group, 38 patients answered the phone. The primary outcome of this study was to compare postoperative average pain and postoperative peak pain using VAS scores between the 2 groups. Secondary outcomes included the comparison of Vaizey scores, duration of analgesic use, use of laxatives, and the incidence rates of specific complications such as postoperative bleeding, rectal stenosis, and rectovaginal fistula.

Surgical procedures

In our study, 2 types of surgeries were performed: CH (Milligan-Morgan hemorrhoidectomy) and mPSH. Milligan-Morgan hemorrhoidectomy was performed according to standard procedures. PSH was performed using a tri-window anoscope to distinguish it from CSH. In PSH, purse-string sutures were applied, and stapling was performed on the 3 prolapsed mucosal tissues protruding through the tri-window. Following this procedure, 3 mucosal bridges were formed between the excised mucosa. These bridges were incised, resulting in 6 mucosal cut ends, which were subjected to suture ligation. This led to partial closure of the hemorrhoidal cushions, effectively reducing their size and restoring their normal anatomy. In the mPSH method, following the insertion of a tri-window anoscope, a mixture of lidocaine and epinephrine (1:200,000) was injected into the area to be sutured. This was performed to minimize pain during stapling and to prevent excessive excision into the muscle layer, thereby reducing the risk of rectovaginal fistula formation while adequately excising the mucosa and submucosa. The 6 edges of the excised mucosa were sutured to prevent postoperative bleeding. If necessary, additional surrounding tissues were included in the suture area to adjust the extent of lifting at the surgeon's discretion (Fig. 2).

Postoperative care for both groups was administered in the same way without any differences. This included standard nursing care during hospitalization, fiber intake, sitz baths, conservative pain management, and antibiotic administration. Acetaminophen (650 mg orally 3 times a day) was administered after surgery, with rescue analgesia using intramuscular ketorolac (30 mg) if needed. If a patient was unable to defecate independently, an enema was administered before discharge. At discharge, patients were prescribed oral antibiotics (metronidazole, 250 mg once daily) and acetaminophen (650 mg 3 times daily for 2 days). Opioid analgesics were not included in the discharge medications. Laxatives such as Fibersol (joint venture between Archer Daniels Midland Company, Matsutani Chemical Industry Co Ltd, and Matsutani America Inc), containing digestion-resistant maltodextrin, were also prescribed, with instructions for self-regulation based on anal discomfort or changes in bowel habits.

Sample size calculation

The minimum sample size of expected study subjects was determined based on considering the difference in VAS between the 2 groups. In our previous studies (unpublished), the difference in VAS was about 2 points, and the standard deviation was 3 or less. In the 2-tailed test, when calculating α error as 0.05 and β error as 0.2, the minimum sample size required was calculated to be 42 people for each group. We recruited a total of 110 patients, assuming a dropout rate of 24%.

Statistical analysis

Categorical variables and complications were analyzed using chi-square and Fisher exact tests. Continuous variables were expressed as mean±standard deviation and compared using the Student t-test. Patients' characteristics and follow-up results were compared between the mPSH and CH groups; VAS was analyzed using the generalized estimating equation method. Statistical significance was set at P<0.05. Statistical analyses were performed using the IBM SPSS ver. 29.0 (IBM Corp).

RESULTS

Patients’ characteristics

There were no significant differences between the groups in terms of demographic data, preoperative anal pressure, hemorrhoidal symptom scores, or incontinence scores. The rate of grade IV hemorrhoids was 7.27% in the mPSH group and 3.63% in the CH group, indicating a higher rate of grade IV hemorrhoids in the mPSH group; however, this difference was not statistically significant (P=0.094) (Tables 1, 2) [20].

Perioperative results

There was no statistically significant difference in the operation time between the 2 groups (P=0.649), indicating comparable surgical efficiency. Although the duration of analgesic requirement tended to be shorter in the mPSH group, this difference was not statistically significant (P=0.096), suggesting a potential but inconclusive advantage of mPSH in pain management. In contrast, notable improvements were observed in various postoperative outcomes in patients who underwent mPSH. Specifically, the mPSH group demonstrated a significantly shorter duration of laxative requirement (P<0.010) and quicker return to work (P<0.010), indicating a faster recovery process. Moreover, patients who underwent mPSH reported higher satisfaction scores (P<0.010) and lower Vaizey scores (P=0.014), indicating improved overall well-being and functional outcomes. Despite these favorable findings, there was no discernible difference in the quality-of-life scores between the 2 groups, as indicated by the similar PCS-12 score (P=0.133) and MCS-12 score (P=0.169) (Table 3).

Nonetheless, postoperative pain management appeared to be more effective in the mPSH group, with average and peak pain scores during the first 15 days postoperatively being statistically significantly lower compared to the CH group (P<0.001). However, the postoperative average pain scores were not statistically significant between the groups starting from the 12th postoperative day (P=0.144). For postoperative peak pain, the difference in pain scores was not statistically significant starting from the 15th postoperative day (P=0.075). Pain scores per day are recorded separately in Fig. 3.

Long-term results and postoperative complications

The overall complication rate in both groups was 9.1%, with no significant difference between the groups (P=0.867) (Table 4). Urinary retention was the most common complication, occurring in 4 cases (7.3%) in each group, and there was 1 case (1.8%) of bleeding in each group. In each bleeding case, bleeding control (via suture ligation) was performed under spinal anesthesia. No additional critical complications, such as stenosis or rectovaginal fistula, were noted during the follow-up period.

The median follow-up duration for both groups was 18 months (range, 10–26 months). The satisfaction scores were 3.71 for the mPSH group and 3.73 for the CH group, with no significant difference between the 2 groups (P=0.889). Additionally, the proportion of patients without prolapse was 97.6% in the mPSH group and 97.3% in the CH group, with no significant difference between the 2 groups (P=0.942) (Table 5).

DISCUSSION

In this study, mPSH performed at our hospital demonstrated statistically significant differences in shorter duration of laxative requirement, quicker return to work, lower Vaizey scores, lower postoperative pain scores, and higher postoperative patient satisfaction compared with the scores observed in CH. Many studies have asserted the advantages of CSH [9, 15, 16, 21]; however, reluctance to perform this procedure can be attributed to rare complications, such as rectovaginal fistula, anastomosis-induced stricture, or persistent bleeding [13, 14, 22, 23]. However, our hospital's modified technique has shown potential in reducing these complications and effectively treating prolapsed hemorrhoids without compromising efficacy compared with CH.

In our study, the overall complication rate was 9.1% in both groups. Urinary retention occurred in 7.1% of cases in both groups. These findings indicate a significantly lower complication rate than the average frequency of complications reported after CSH surgery (20.2%) in other meta-analyses [24]. Furthermore, the average prolapse recurrence rate in our study was 2.6% in both groups, and the bleeding rate remained consistent at 1.8% across both groups. These findings suggest a lower complication rate than that reported in other studies. Goldstein et al. [25] reported a postoperative bleeding rate of 21.7%, whereas Festen et al. [26] observed persistence and recurrence of prolapse at a rate of 16%.

In Korea, purse-string suturing is typically performed at a lower level during CSH than the level predominantly used in other countries, with the aim of reducing recurrence rates and achieving a better anal appearance after surgery [27]. In our institution, lower purse-string levels are preferred during mPSH. During the purse-string suture, the 3 parts protruding through the tri-window anoscope were sutured twice. Initially, suturing begins 2.5 cm above the dentate line; in cases of severe prolapse, the spacing between the first and second sutures was widened to allow for extensive resection and lifting. Additionally, when suturing the mucosal cut ends, the surrounding tissues were included in the ligation if necessary. These procedural differences may have contributed to the differences in recurrence rates. Considering the above complication rates, we believe that our study demonstrates the excellent treatment effectiveness and safety achieved through the mPSH.

This study had several limitations. First, although this was a prospective RCT aimed at minimizing bias, the characteristics of a single center and the lack of blinding for the surgeon regarding patient information after surgery due to single blinding randomization limit the generalizability of the results and may lead to potential selection bias. Second, there was a lack of control for lifestyle modifications such as dietary habits and other comorbidities, which could influence the long-term outcomes and complications of the procedure. Third, the rate of grade IV hemorrhoids in our study was 7.27% for mPSH and 3.63% for CH, which was lower than the rates reported in other studies (e.g., 27%–34% in Lin et al. [28]). Additional research is required to evaluate the effectiveness of mPSH, particularly in patients with grade IV hemorrhoids. Fourth, although the average follow-up period in this study was 18 months, it is essential to conduct further investigations through hospital visits to objectively assess whether improvements in hemorrhoidal symptoms and recurrence rates of prolapse are sustained over a long-term follow-up period, considering that the evaluation was based on subjective symptoms reported via telephone rather than an objective assessment by a physician. Fifth, although there was a statistically significant difference in average pain scores and peak pain scores measured daily for up to 15 days between the 2 groups, the pain score difference decreased over time. Therefore, it was not possible to determine statistically significant pain differences between the 2 groups beyond a certain point. Additional research at that certain point is needed. However, this is the first prospective randomized controlled trial comparing mPSH and CH. Through systematic randomization and standardized data collection procedures, we provided a comprehensive evaluation of the differences between efficacy and safety associated with mPSH and CH.

Future studies should include information on sensitive topics, such as sexual intercourse. For example, dyspareunia lasting longer than 2 months was reported in a French multicenter study [29]; however, the authors did not specify whether sexual practices were conventional. Including such details in future research will provide a clearer understanding of the potential impact of surgical interventions on the sexual health and well-being of patients. Anal intercourse after CSH increases the risk of condom damage and penile injuries. This could serve as a risk factor for exposure to sexually transmitted diseases [30].

In conclusion, this study found that mPSH, compared to CH, was associated with better improvement in symptoms, lower pain scores and greater patient early satisfaction after surgery with comparable long-term outcome. Therefore, mPSH appears to be a safe and effective alternative to CH.

ARTICLE INFORMATION

Conflict of interest

Chul Seung Lee is an editorial board member of this journal, but was not involved in the peer reviewer selection, evaluation, or decision process of this article. No other potential conflict of interest relevant to this article was reported.

Funding

None.

Author contributions

Conceptualization: TGK, GYJ, CSL; Data curation: TGK, GYJ, CSL; Formal analysis: TGK, GYJ, CSL; Investigation: TGK, GYJ, CSL; Methodology: TGK, GYJ, CSL; Project administration: GYJ; Resources: all authors; Software: all authors; Supervision: GYJ, CSL; Validation: all authors; Visualization: TGK; Writing–original draft: TGK; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Additional information

This study was previously shared as a preprint on Research Square (https://doi.org/10.21203/rs.3.rs-4482264/v1) and has since undergone peer review for publication in this journal.

Supplementary materials

Supplementary Table 1.

CONSORT (Consolidated Standards of Reporting Trials) 2010 checklist

ac-2024-00535-0076-Supplementary-Table-1.pdf

Supplementary materials are available from https://doi.org/10.3393/ac.2024.00535.0076.

Fig. 1.

Study flowchart. NSAID, nonsteroidal anti-inflammatory; mPSH, modified partial stapled hemorrhoidopexy; CH, conventional hemorrhoidectomy.

Fig. 2.

Preoperative and postoperative findings. (A) Preoperative image of prolapsed hemorrhoid. (B) A tri-window anoscope inserted, before a mixture of lidocaine and epinephrine is injected. (C) The inserted tri-window anoscope being injected. (D) A tri-window anoscope inserted, after injection. (E) After circular stapler firing status. (F) Suture ligation on 6 excised mucosal end to prevent postoperative bleeding. (G) Postoperative image of complete reduction of the prolapse by modified partial stapled hemorrhoidopexy method.

Fig. 3.

Postoperative pain scores measured by visual analog scale (VAS) were compared between the conventional hemorrhoidectomy (CH) group and the modified partial stapled hemorrhoidopexy (mPSH) group using the generalized estimating equation method. (A) The postoperative average pain VAS score in the mPSH group was significantly lower than the CH group (P<0.001). (B) The postoperative peak pain VAS score in the mPSH group was significantly lower than the CH group (P<0.001).

Table 1.

Hemorrhoidal symptom score

Symptom	Score
Symptom	0	1	2	3	4
Bleeding	Never	At least once per year	At least once per month	At least once per week	With every bowel movement
Prolapse	Never	At least once per year	At least once per month	At least once per week	With every bowel movement
Manual reduction	Never	At least once per year	At least once per month	At least once per week	With every bowel movement
Discomfort and pain	Never	At least once per year	At least once per month	At least once per week	With every bowel movement

Adapted from Giordano et al. [20], available under the Creative Commons Attribution Noncommercial License.

Table 2.

Baseline characteristics (n=110)

Characteristic	mPSH group (n=55)	CH group (n=55)	P-value
Age (yr)	47.40±15.48	46.47±6.89	0.646
Male sex	34 (61.8)	32 (58.2)	0.700
ASA physical status	1.21±0.13	1.21 ±0.08	0.986
Body mass index (kg/m²)	23.69±8.79	23.13±5.65	0.278
Grade IV hemorrhoid (%)	4 (7.3)	2 (3.6)	0.094
External hemorrhoid (yes) (%)	30 (54.5)	27 (49.1)	0.529
Resting pressure (mmHg)	45.12±4.57	44.82±3.27	0.937
Squeezing pressure (mmHg)	103.51±14.21	105.94±20.75	0.760
Hemorrhoidal symptom score^a	8.95±1.90	8.55±0.70	0.567
Vaizey score^b	3.72±0.17	4.24±0.12	0.483

Values are presented as mean±standard deviation or number (%).

mPSH, modified partial stapled hemorrhoidopexy; CH, conventional hemorrhoidectomy; ASA, American Society of Anesthesiologists.

^aSee Table 1 for each item of score.

^bRange, 0 (perfect continence) to 24 (totally incontinent).

Table 3.

Perioperative results (n=110)

Variable	mPSH group (n=55)	CH group (n=55)	P-value
Operation time (min)	32.24±3.68	32.82±5.30	0.649
Analgesic requirement (day)	10.61±1.64	11.96±1.87	0.096
Laxative requirement (day)	8.91±4.51	15.87±5.55	<0.010
Return to work (day)	6.07±0.94	7.52±0.69	<0.010
Satisfaction score^a	3.01±0.76	2.00±0.26	<0.010
Vaizey score^b	3.85±0.13	5.35±0.06	0.014
12-Item Short Form Health Survey^c
PCS-12	46.45±4.22	48.04±1.82	0.133
MCS-12	51.60±10.99	49.47±2.01	0.169

Values are presented as mean±standard deviation.

mPSH, modified partial stapled hemorrhoidopexy; CH, conventional hemorrhoidectomy; PCS, Physical Health Component Summary; MCS, Mental Health Component Summary.

^aRange, 0 (no satisfaction) to 4 (excellent satisfaction).

^bRange, 0 (perfect continence) to 24 (totally incontinent).

^cRange, 0 (not healthy state) to 100 (healthy state).

Table 4.

Overall complication (n=110)

Complication	No. of patients (%)		P-value
Complication	mPSH group (n=55)	CH group (n=55)	P-value
Overall	5 (9.1)	5 (9.1)	0.867
Urinary retention	4 (7.3)	4 (7.3)
Local infection	0 (0)	0 (0)
Bleeding	1 (1.8)	1 (1.8)
Intractable pain	0 (0)	0 (0)
Stenosis	0 (0)	0 (0)
Rectovaginal fistula	0 (0)	0 (0)

mPSH, modified partial stapled hemorrhoidopexy; CH, conventional hemorrhoidectomy.

Table 5.

Long-term result (n=78)

Variable	mPSH group (n=41)	CH group (n=37)	P-value
Satisfaction score^a	3.71	3.73	0.889
Absence of prolapse (patient self-reported)	40 (97.6)	36 (97.3)	0.942

Values are presented as mean only or number (%). The mean follow-up duration for both groups was 18.19 months.

mPSH, modified partial stapled hemorrhoidopexy; CH, conventional hemorrhoidectomy.

^aRange, 0 (no satisfaction) to 4 (excellent satisfaction).

REFERENCES

1. Lee JH, Kim HE, Kang JH, Shin JY, Song YM. Factors associated with hemorrhoids in Korean adults: Korean national health and nutrition examination survey. Korean J Fam Med 2014;35:227–36. Article PubMed PMC
2. Bleday R, Pena JP, Rothenberger DA, Goldberg SM, Buls JG. Symptomatic hemorrhoids: current incidence and complications of operative therapy. Dis Colon Rectum 1992;35:477–81. Article PubMed
3. Riss S, Weiser FA, Schwameis K, Riss T, Mittlböck M, Steiner G, et al. The prevalence of hemorrhoids in adults. Int J Colorectal Dis 2012;27:215–20. Article PubMed PDF
4. Morinaga K, Hasuda K, Ikeda T. A novel therapy for internal hemorrhoids: ligation of the hemorrhoidal artery with a newly devised instrument (Moricorn) in conjunction with a Doppler flowmeter. Am J Gastroenterol 1995;90:610–3. PubMed
5. Ganz RA. The evaluation and treatment of hemorrhoids: a guide for the gastroenterologist. Clin Gastroenterol Hepatol 2013;11:593–603. Article PubMed
6. Guttenplan M. The evaluation and office management of hemorrhoids for the gastroenterologist. Curr Gastroenterol Rep 2017;19:30.Article PubMed PDF
7. Moult HP, Aubert M, De Parades V. Classical treatment of hemorrhoids. J Visc Surg 2015;152(2 Suppl): S3–9. Article
8. Parks AG. The surgical treatment of haemorrhoids. Br J Surg 1956;43:337–51. Article PubMed
9. Sultan S. Longo procedure (Stapled hemorrhoidopexy): indications, results. J Visc Surg 2015;152(2 Suppl): S11–4. Article PubMed
10. Pescatori M, Gagliardi G. Postoperative complications after procedure for prolapsed hemorrhoids (PPH) and stapled transanal rectal resection (STARR) procedures. Tech Coloproctol 2008;12:7–19. Article PubMed PMC PDF
11. Porrett LJ, Porrett JK, Ho YH. Documented complications of staple hemorrhoidopexy: a systematic review. Int Surg 2015;100:44–57. Article PubMed PMC PDF
12. Ravo B, Amato A, Bianco V, Boccasanta P, Bottini C, Carriero A, et al. Complications after stapled hemorrhoidectomy: can they be prevented? Tech Coloproctol 2002;6:83–8. Article PubMed PDF
13. Cirocco WC. Life threatening sepsis and mortality following stapled hemorrhoidopexy. Surgery 2008;143:824–9. Article PubMed
14. McDonald PJ, Bona R, Cohen CR. Rectovaginal fistula after stapled haemorrhoidopexy. Colorectal Dis 2004;6:64–5. Article PubMed
15. Sturiale A, Dowais R, Fabiani B, Menconi C, Porzio FC, Coli V, et al. Long-term outcomes of high-volume stapled hemorroidopexy to treat symptomatic hemorrhoidal disease. Ann Coloproctol 2023;39:11–6. Article PubMed PDF
16. Lin HC, He QL, Ren DL, Peng H, Xie SK, Su D, et al. Partial stapled hemorrhoidopexy: a minimally invasive technique for hemorrhoids. Surg Today 2012;42:868–75. Article PubMed PDF
17. Kim JS. Partial stapled hemorrhoidopexy versus circular stapled hemorrhoidopexy. Ann Coloproctol 2017;33:7–8. Article PubMed PMC PDF
18. Lin HC, Ren DL, He QL, Peng H, Xie SK, Su D, et al. Partial stapled hemorrhoidopexy versus circular stapled hemorrhoidopexy for grade III-IV prolapsing hemorrhoids: a two-year prospective controlled study. Tech Coloproctol 2012;16:337–43. Article PubMed PDF
19. Lin HC, Luo HX, Zbar AP, Xie SK, Lian L, Ren DL, et al. The tissue selecting technique (TST) versus the Milligan-Morgan hemorrhoidectomy for prolapsing hemorrhoids: a retrospective case-control study. Tech Coloproctol 2014;18:739–44. Article PubMed PDF
20. Giordano P, Nastro P, Davies A, Gravante G. Prospective evaluation of stapled haemorrhoidopexy versus transanal haemorrhoidal dearterialisation for stage II and III haemorrhoids: three-year outcomes. Tech Coloproctol 2011;15:67–73. Article PubMed PMC
21. Giordano P, Gravante G, Sorge R, Ovens L, Nastro P. Long-term outcomes of stapled hemorrhoidopexy vs conventional hemorrhoidectomy: a meta-analysis of randomized controlled trials. Arch Surg 2009;144:266–72. Article PubMed
22. Ielpo B, Venditti D, Balassone V, Favetta U, Buonomo O, Petrella G. Proctalgia as a late complication of stapled hemorrhoidectomy: report of our case series. Int J Surg 2010;8:648–52. Article PubMed
23. Lee SD, Jung ST, Lee JB, Kim MJ, Lee DS, Youk EG, et al. Persistent bleeding following a stapled hemorrhoidopexy. Ann Coloproctol 2016;32:120–2. Article PubMed PMC
24. Tjandra JJ, Chan MK. Systematic review on the procedure for prolapse and hemorrhoids (stapled hemorrhoidopexy). Dis Colon Rectum 2007;50:878–92. Article PubMed
25. Goldstein SD, Meslin KP, Mazza T, Isenberg GA, Fitzgerald J, Richards A, et al. Stapled hemorrhoidopexy: outcome assessment. Am Surg 2007;73:733–6. Article PubMed PDF
26. Festen S, Molthof H, van Geloven AA, Luchters S, Gerhards MF. Predictors of recurrence of prolapse after procedure for prolapse and haemorrhoids. Colorectal Dis 2012;14:989–96. Article PubMed
27. Jeong H, Hwang S, Ryu KO, Lim J, Kim HT, Yu HM, et al. Early experience with a partial stapled hemorrhoidopexy for treating patients with grades III-IV prolapsing hemorrhoids. Ann Coloproctol 2017;33:28–34. Article PubMed PMC PDF
28. Lin HC, He QL, Shao WJ, Chen XL, Peng H, Xie SK, et al. Partial stapled hemorrhoidopexy versus circumferential stapled hemorrhoidopexy for grade III to IV prolapsing hemorrhoids: a randomized, noninferiority trial. Dis Colon Rectum 2019;62:223–33. Article PubMed
29. Oughriss M, Yver R, Faucheron JL. Complications of stapled hemorrhoidectomy: a French multicentric study. Gastroenterol Clin Biol 2005;29:429–33. Article PubMed
30. Kekez T, Bulic K, Smudj D, Majerovic M. Is stapled hemorrhoidopexy safe for the male homosexual patient? Report of a case. Surg Today 2007;37:335–7. Article PubMed PDF

Figure & Data

References

Citations

Citations to this article as recorded by

Cite this Article

Cite this Article: export Copy Download Format; Close

Download Citation

Download a citation file in RIS format that can be imported by all major citation management software, including EndNote, ProCite, RefWorks, and Reference Manager.

Format:

RIS — For EndNote, ProCite, RefWorks, and most other reference management software
BibTeX — For JabRef, BibDesk, and other BibTeX-specific software

Include:

Citation for the content below
Citation and abstract for the content below

A comparative study on efficacy and safety of modified partial stapled hemorrhoidopexy versus conventional hemorrhoidectomy: a prospective randomized controlled trial

Ann Coloproctol. 2025;41(2):145-153. Published online April 28, 2025

DOI: https://doi.org/10.3393/ac.2024.00535.0076

XML Download

Figure

Related articles

Comments on “Laser hemorrhoidoplasty versus conventional hemorrhoidectomy for grade II/III hemorrhoids: a systematic review and meta-analysis”

A comparative study on efficacy and safety of modified partial stapled hemorrhoidopexy versus conventional hemorrhoidectomy: a prospective randomized controlled trial

Fig. 1. Study flowchart. NSAID, nonsteroidal anti-inflammatory; mPSH, modified partial stapled hemorrhoidopexy; CH, conventional hemorrhoidectomy.

Fig. 2. Preoperative and postoperative findings. (A) Preoperative image of prolapsed hemorrhoid. (B) A tri-window anoscope inserted, before a mixture of lidocaine and epinephrine is injected. (C) The inserted tri-window anoscope being injected. (D) A tri-window anoscope inserted, after injection. (E) After circular stapler firing status. (F) Suture ligation on 6 excised mucosal end to prevent postoperative bleeding. (G) Postoperative image of complete reduction of the prolapse by modified partial stapled hemorrhoidopexy method.

Fig. 3. Postoperative pain scores measured by visual analog scale (VAS) were compared between the conventional hemorrhoidectomy (CH) group and the modified partial stapled hemorrhoidopexy (mPSH) group using the generalized estimating equation method. (A) The postoperative average pain VAS score in the mPSH group was significantly lower than the CH group (P<0.001). (B) The postoperative peak pain VAS score in the mPSH group was significantly lower than the CH group (P<0.001).

Fig. 1.

Fig. 2.

Fig. 3.

A comparative study on efficacy and safety of modified partial stapled hemorrhoidopexy versus conventional hemorrhoidectomy: a prospective randomized controlled trial

Symptom	Score
Symptom	0	1	2	3	4
Bleeding	Never	At least once per year	At least once per month	At least once per week	With every bowel movement
Prolapse	Never	At least once per year	At least once per month	At least once per week	With every bowel movement
Manual reduction	Never	At least once per year	At least once per month	At least once per week	With every bowel movement
Discomfort and pain	Never	At least once per year	At least once per month	At least once per week	With every bowel movement

Characteristic	mPSH group (n=55)	CH group (n=55)	P-value
Age (yr)	47.40±15.48	46.47±6.89	0.646
Male sex	34 (61.8)	32 (58.2)	0.700
ASA physical status	1.21±0.13	1.21 ±0.08	0.986
Body mass index (kg/m²)	23.69±8.79	23.13±5.65	0.278
Grade IV hemorrhoid (%)	4 (7.3)	2 (3.6)	0.094
External hemorrhoid (yes) (%)	30 (54.5)	27 (49.1)	0.529
Resting pressure (mmHg)	45.12±4.57	44.82±3.27	0.937
Squeezing pressure (mmHg)	103.51±14.21	105.94±20.75	0.760
Hemorrhoidal symptom score^a	8.95±1.90	8.55±0.70	0.567
Vaizey score^b	3.72±0.17	4.24±0.12	0.483

Variable	mPSH group (n=55)	CH group (n=55)	P-value
Operation time (min)	32.24±3.68	32.82±5.30	0.649
Analgesic requirement (day)	10.61±1.64	11.96±1.87	0.096
Laxative requirement (day)	8.91±4.51	15.87±5.55	<0.010
Return to work (day)	6.07±0.94	7.52±0.69	<0.010
Satisfaction score^a	3.01±0.76	2.00±0.26	<0.010
Vaizey score^b	3.85±0.13	5.35±0.06	0.014
12-Item Short Form Health Survey^c
PCS-12	46.45±4.22	48.04±1.82	0.133
MCS-12	51.60±10.99	49.47±2.01	0.169

Complication	No. of patients (%)		P-value
Complication	mPSH group (n=55)	CH group (n=55)	P-value
Overall	5 (9.1)	5 (9.1)	0.867
Urinary retention	4 (7.3)	4 (7.3)
Local infection	0 (0)	0 (0)
Bleeding	1 (1.8)	1 (1.8)
Intractable pain	0 (0)	0 (0)
Stenosis	0 (0)	0 (0)
Rectovaginal fistula	0 (0)	0 (0)

Variable	mPSH group (n=41)	CH group (n=37)	P-value
Satisfaction score^a	3.71	3.73	0.889
Absence of prolapse (patient self-reported)	40 (97.6)	36 (97.3)	0.942

Table 1. Hemorrhoidal symptom score

Adapted from Giordano et al. [20], available under the Creative Commons Attribution Noncommercial License.

Table 2. Baseline characteristics (n=110)

Values are presented as mean±standard deviation or number (%).

mPSH, modified partial stapled hemorrhoidopexy; CH, conventional hemorrhoidectomy; ASA, American Society of Anesthesiologists.

See Table 1 for each item of score.

Range, 0 (perfect continence) to 24 (totally incontinent).

Table 3. Perioperative results (n=110)

Values are presented as mean±standard deviation.

mPSH, modified partial stapled hemorrhoidopexy; CH, conventional hemorrhoidectomy; PCS, Physical Health Component Summary; MCS, Mental Health Component Summary.

Range, 0 (no satisfaction) to 4 (excellent satisfaction).

Range, 0 (perfect continence) to 24 (totally incontinent).

Range, 0 (not healthy state) to 100 (healthy state).

Table 4. Overall complication (n=110)

mPSH, modified partial stapled hemorrhoidopexy; CH, conventional hemorrhoidectomy.

Table 5. Long-term result (n=78)

Values are presented as mean only or number (%). The mean follow-up duration for both groups was 18.19 months.

mPSH, modified partial stapled hemorrhoidopexy; CH, conventional hemorrhoidectomy.