Background: This dissertation is composed of five individual studies of the stapled haemorrhoidopexy operation. The operation was launched to an international audience in 1998 by the Italian surgeon Antonio Longo. In conventional surgery the prolapsed piles are excised from the anodermal part of the prolapse up through the anal canal into the lower rectal mucosa where the pile is divided with diathermy or suture ligated and excised. It leaves open wounds throughout the anal canal. These wounds can be very painful, especially at defecation, and will take from three to six weeks to heal. In the stapled haemorrhoidopexy operation symptomatic haemorrhoids are seen as a disease of anodermal, haemorrhoidal and rectal mucosal prolapse of varying degree. The main component of the prolapse is the redundancy of rectal mucosa. By pushing back the prolapse into the anal canal followed by excision of the mucosal redundancy above the anal canal with a circular stapler devise a mucosal anastomosis is fashioned. This anastomosis is situated immediately above the haemorrhoids and will attach them to the rectal muscular wall to prevent further prolapse. The operation is associated with substantially less pain and a quicker recovery. Methods: For the five studies, a total of 334 patients were operated for haemorrhoidal prolapse. The first operations were performed in February 1998. All patients were assessed preoperatively and postoperatively with the same set of protocols as follows. The symptoms of haemorrhoids were scored with a questionnaire to patients to obtain their independent statements of the frequency of each of five cardinal symptoms: pain, bleeding, pruritus, soiling and prolapse in need of manual reduction. A diary was used by patients to report daily pain scores, use of pain medication and speed of recovery within the first 14 postoperative days. The surgeon rated the deranged anal anatomy before and after surgery. We also developed an algorithm based on the patients’ statement of digital reduction of prolapse (grade 3) and the surgeon’s assessment of lesser prolapse at proctoscopy (grade 2). Absence of prolapse was grade 1. The surgeon also provided statements about the conduct of the operation and rated the technical complexity. The information, for all patients, was entered into an electronic data base. Results: One registry based study and one prospective randomised controlled trial assessed the advantage of performing the operation under perianal local anaesthetic block. The postoperative pain and surgical outcome was independent of the type of anaesthesia. No operation under local block had to be converted to general anaesthesia. Anodermal prolapse is seen in 70 percent of the patients. In a registry-based study we found that excision of the anodermal folds did not increase the postoperative pain provided the excision stopped at the anal verge. In 270 patients with precise preoperative and postoperative classification we found that the symptomatic load was identical for grades 2 and 3. The symptoms were independent of the anodermal prolapse. The symptoms were greatly reduced when the operation turned out grade 1 prolapse. The long-term result was assessed in 153 patients operated 1 year to 6 years previously. The need for early re-intervention was 6.2 percent representing technical error to reduce the prolapse. At the final evaluation 12 patients (8.2 percent) complained of a mucoanal prolapse in need of digital reduction. The mean symptom burden had been reduced from 8.1 to 2.5 points but 17 percent had at least one cardinal symptom with a weekly frequency. Conclusions: Stapled haemorrhoidopexy should be performed as day surgery under local anaesthesia. Any remaining anodermal prolapse should be excised. The optimal long-term outcome is grade 1A or 1B with low symptom score. There was an 87 percent chance of cure of the prolapse with the first haemorrhoidopexy. About half the failures were insufficient primary surgery and half a relapse of the prolapse. / <p>The original title of article IV was "Prolapse grade and symptoms of haemorrhoids are poorly correlated: result of a classification algorithm in 270 patients. The new title after publishing the article is "Grade of prolapse and symptoms of haemorrhoids are poorly correlated: result of a classification algorithm in 270 patients".</p>

<p>One hundred haemorrhoid patients were compared with 300 matched control persons. Haemorrhoid symptoms and bowel symptoms were studied. Most common symptom of the patients was bleeding (44%), followed by prolapse (24%), hygiene problem (14%), pain (12%) and itching (5%). Bowel symptoms, as bloating and evacuation difficulties, possibly related to IBS, were frequent among the patients.</p><p>556 patients were operated upon with Milligan-Morgan haemorrhoidectomy. 418 (81%) answered a questionnaire on results, and on disturbances in anal continence. Totally140 (33%) reported recurrence, and 139 (33%) patients reported anal incontinence. Forty of the 139 patients associated this to the surgical procedure. Female gender was associated to increased risk of incontinence.</p><p>The 40 patients who reported incontinence, were invited to undergo ano-rectal manometry, saline infusion test, endo-anal ultrasound, proctoscopy and clinical examination. Altogether 19 patients approved to participate. Matched control subjects and 15 persons previously operated for haemorrhoids, but without symptoms of incontinence, served as two reference groups. Incontinence score and saline infusion test showed significantly poorer continence in the patient group. Endo-anal ultrasound showed injury to the external sphincter in 20% of the patients. Anal pressure was slightly lower in the patient group, but the difference was not significant. </p><p>Totally 225 patients were randomised to Milligan-Morgan or Ferguson haemorrhoidectomy. Primary aim was to study changes in anal continence. Other aims were to study postoperative pain, wound healing, complications, patient satisfaction and recurrence and changes in bowel function. Patients in the Ferguson group reported, slightly quicker wound healing (P=0.06). Postoperative pain was equal, as was rate of complications. After one year the Ferguson group reported lower incontinence score, and more satisfied patients. Recurrence rate was equal, 15-17%. Most bowel symptoms were reduced one year after surgery.</p><p>In conclusion, functional bowel symptoms are common in haemorrhoid patients. Haemorrhoidectomy is associated with risk for incontinence in 5-10% of patients and females are at greater risk. A proportion of the patients who claim postoperative incontinence have physiological signs of sphincter incompetence, and external sphincter injuries are observed in those patients. Ferguson haemorrhoidectomy results in better anal continence and more satisfied patients. </p>

One hundred haemorrhoid patients were compared with 300 matched control persons. Haemorrhoid symptoms and bowel symptoms were studied. Most common symptom of the patients was bleeding (44%), followed by prolapse (24%), hygiene problem (14%), pain (12%) and itching (5%). Bowel symptoms, as bloating and evacuation difficulties, possibly related to IBS, were frequent among the patients. 556 patients were operated upon with Milligan-Morgan haemorrhoidectomy. 418 (81%) answered a questionnaire on results, and on disturbances in anal continence. Totally140 (33%) reported recurrence, and 139 (33%) patients reported anal incontinence. Forty of the 139 patients associated this to the surgical procedure. Female gender was associated to increased risk of incontinence. The 40 patients who reported incontinence, were invited to undergo ano-rectal manometry, saline infusion test, endo-anal ultrasound, proctoscopy and clinical examination. Altogether 19 patients approved to participate. Matched control subjects and 15 persons previously operated for haemorrhoids, but without symptoms of incontinence, served as two reference groups. Incontinence score and saline infusion test showed significantly poorer continence in the patient group. Endo-anal ultrasound showed injury to the external sphincter in 20% of the patients. Anal pressure was slightly lower in the patient group, but the difference was not significant. Totally 225 patients were randomised to Milligan-Morgan or Ferguson haemorrhoidectomy. Primary aim was to study changes in anal continence. Other aims were to study postoperative pain, wound healing, complications, patient satisfaction and recurrence and changes in bowel function. Patients in the Ferguson group reported, slightly quicker wound healing (P=0.06). Postoperative pain was equal, as was rate of complications. After one year the Ferguson group reported lower incontinence score, and more satisfied patients. Recurrence rate was equal, 15-17%. Most bowel symptoms were reduced one year after surgery. In conclusion, functional bowel symptoms are common in haemorrhoid patients. Haemorrhoidectomy is associated with risk for incontinence in 5-10% of patients and females are at greater risk. A proportion of the patients who claim postoperative incontinence have physiological signs of sphincter incompetence, and external sphincter injuries are observed in those patients. Ferguson haemorrhoidectomy results in better anal continence and more satisfied patients.

Conselho Nacional de Desenvolvimento CientÃfico e TecnolÃgico / O tratamento cirÃrgico da doenÃa hemorroidÃria pela Anopexia MecÃnica (AM), utilizando grampeador circular PPH de 33mm (Ethicon EndoSurgery) pode estar relacionado a lesÃo esfincteriana perianal, com repercussÃo no padrÃo evacuatÃrio. O objetivo deste estudo à avaliar a sensibilidade e complacÃncia retal em pacientes submetidos a esta tÃcnica operatÃria. Foram estudados 10 pacientes portadores de hemorrÃidas grau III ou IV sintomÃticas. Todos os pacientes foram avaliados prÃ-operatoriamante utilizando-se um barostato (Visceral Stimulator; Synetics Medical), com base em dois protocolos de pesquisa da sensibilidade retal: um contÃnuo (Ramp Test) e outro aleatÃrio (Random test), nos quais foram aferidas as diferentes reaÃÃes dos pacientes frente à distensÃo volumÃtrica de um balÃo retal sob controle de um "software" (Polygram for Windows; Medtronic), o que permitiu a reprodutibilidade do mÃtodo no pÃs-operatÃrio. Foram observadas a sensaÃÃo retal inicial (1a. sensaÃÃo), a sensibilidade evacuatÃria (2a. sensaÃÃo) e a sensibilidade a dor (3a. sensaÃÃo). ApÃs cirurgia os pacientes foram reavaliados ao final de 2, 4 e 6 meses. Utilizou-se um grupo controle de 10 pacientes portadores de doenÃa pilonidal sacro-coccÃgea, submetidos ao mesmo protocolo de avaliaÃÃo no prà e pÃs-operatÃrio, diferenciando-os do grupo cirÃrgico pela nÃo realizaÃÃo da anopexia mecÃnica. Foram aplicados os testes estatÃsticos de Pearson e t-student para a anÃlise dos estatÃstica dos resultados. Observou-se diminuiÃÃo dos valores de complacÃncia e sensibilidade retal ao final de 2 meses de pÃs-operatÃrio no grupo submetido a AM, para todas as sensaÃÃes pesquisadas, em ambos os protocolos de insuflaÃÃo do barostato. NÃo se observou diferenÃa entre a complacÃncia e sensibilidade retal observada nas avaliaÃÃes prÃ-operatÃria e aos quatro e seis meses no grupo submetido a AM, bem como em nenhuma das avaliaÃÃes realizadas no grupo controle. Conclui-se que a Anopexia MecÃnica causa uma diminuiÃÃo transitÃria da complacÃncia e sensibilidade retal aos dois meses de pÃs-operatÃrio, valores estes que se recuperam a partir do quarto mÃs pÃs-operatÃrio. / Post-graduation Course in Surgery (Strictu Sensu), Departament of Surgery, Medicine School, Federal University of Cearà (Master in Surgery Degree). 2005, September. Professor: Prof. Dr. Lusmar Veras Rodrigues Surgical treatment of haemorrhoids by Stapled Anopexy (SA), using a circular stapler PPH - 33mm (Ethicon EndoSurgery) may damage perianal muscle fibers, with changes In defecation pattern. The aim of this study was to evaluate rectal compliance and sensitivity in patients treated by SA. Ten patients with grade III or IV sintomatic haemorrhoids were elegible for this study. All patients were studied before surgery with a barostat (Visceral Stimulator; Synetics Medical), using two research protocols for rectal sensitivity: a continuous one (Ramp Test) and another one in steps (Random test), that could record patient's perception to volumetric distention of a rectal baloon, controled by a software (Polygram for Windows, Medtronic). This software made the method reproductible to all patients in the post-operative period. The barostat was able to record the first rectal sensation (1st. sensation), urge to defecate (2nd. sensation) and rectal pain (3rd. sensation). Patients were studied following the same protocol at two, four and six months after surgery. A control group of ten patients with pilonidal sinus disease was submitted to the same protocol, except for stapled anopexy. Statistical analysis was acomplished using Pearson and Student's t test. The study found a decrease in retal compliance and sensitivity of patients treated by stapled anopexy, during the second post-operative month evaluation, for all recorded sensations, to all distension protocols. There was no difference in rectal compliance and sensitivity between pre-operative and post-operative at four and six months evaluations for patients treated by stapled anopexy. There was no difference in rectal compliance and sensitivity for any patient in control group, for any sensation recordered, using any distension protocol. The conclusion was that stapled anopexy caused a transient decrease in rectal compliance and sensitivity at the second postoperative month, that returned to normal values at the fourth post-operative month.