European Journal of Cardiovascular Medicine

Haemorrhoids, commonly referred to as piles, are a prevalent condition that affects a significant portion of the adult population worldwide. This condition is characterized by the swelling and inflammation of the vascular structures in the anal canal, which can lead to discomfort, bleeding, and other symptoms that can significantly impair an individual's quality of life. The treatment modalities for haemorrhoids vary from conservative management to surgical interventions, depending on the severity and persistence of the condition. Among surgical options, haemorrhoidectomy stands out as a definitive treatment for advanced cases of haemorrhoids [1].

This study aims to conduct a prospective comparative study between two prominent surgical techniques for haemorrhoidectomy: the conventional (excisional) haemorrhoidectomy and the stapled haemorrhoidectomy, focusing on their effectiveness, patient acceptance, outcomes, complications, and cost-benefit analysis. Conventional haemorrhoidectomy, also known as excisional haemorrhoidectomy, has been the gold standard for the surgical treatment of severe haemorrhoids for many years. This method involves the excision of the hemorrhoidal tissue and, subsequently, the suture of the wound. Despite its effectiveness in removing hemorrhoidal tissue and alleviating symptoms, conventional haemorrhoidectomy is often associated with significant postoperative pain and a longer recovery period, which can be a substantial drawback for the patient's quality of life post-surgery [2].

On the other hand, stapled haemorrhoidectomy, introduced in the late 1990s, represents a less invasive surgical technique. Also known as the procedure for prolapse and haemorrhoids (PPH), this method involves resecting a band of the prolapsed rectal mucosa above the haemorrhoids and stapling the remaining tissue back to its original position. The primary advantage of this technique is the preservation of the anoderm and the reduction of postoperative pain compared to conventional haemorrhoidectomy. Additionally, stapled haemorrhoidectomy has been reported to offer a shorter operative time, quicker recovery, and earlier return to normal activities [3]. Stapled haemorrhoidectomy's effectiveness across different types and stages of haemorrhoids remains a subject of ongoing research. Initial studies have demonstrated promising results, particularly in patients with circumferential prolapsed haemorrhoids. This thesis will explore the effectiveness of stapled haemorrhoidectomy in treating various haemorrhoid varieties, providing a comprehensive overview of its applicability and success rate compared to conventional methods [4]. Patient acceptance is a critical factor in the evaluation of a surgical technique. Factors influencing acceptance include postoperative pain, recovery time, and overall satisfaction with the procedure's outcomes [5].

This study explores the comparative outcomes of stapled and conventional hemorrhoidectomy in managing advanced hemorrhoids. It hypothesizes that stapled hemorrhoidectomy is equally or more effective than the conventional approach, with the added benefits of better patient acceptance, lower rates of early and late postoperative complications, and a more favorable cost-benefit ratio. By evaluating these factors, the study seeks to provide robust evidence to guide the choice of surgical technique in clinical practice. The research addresses several key questions. It aims to determine the effectiveness of stapled haemorrhoidectomy in the treatment of advanced hemorrhoids and to assess the level of patient acceptance for this method compared to the conventional approach. Additionally, the study seeks to investigate differences in postoperative outcomes between the two techniques, focusing on the rates of early and late complications. Finally, it examines the cost-effectiveness of stapled hemorrhoidectomy relative to the conventional method, highlighting the financial implications of each surgical option. Through these objectives, the study aspires to present a comprehensive analysis of the two surgical techniques, ultimately contributing valuable insights to the field of haemorrhoid management. This structured approach underscores the significance of patient-centered outcomes, surgical effectiveness, and economic considerations, ensuring the findings are both clinically relevant and impactful.

This study was conducted in the Department of General Surgery, Maharaja Agrasen Hospital, New Delhi, as a prospective observational study over a period of 18 months, from July 2022 to January 2024.

Inclusion Criteria: The study population consisted of patients with symptomatic Grade II/III hemorrhoids and prolapsed piles, selected randomly.

Exclusion Criteria: Patients with additional anorectal pathologies such as fistula, malignancy, growth, or abscess were excluded.

Sample Size: A total of 60 patients were included, divided equally into two groups for stapled and open hemorrhoidectomy.

The sample size was calculated based on the formula for comparing two independent means, requiring 31 patients per group to achieve 80% power at a 95% confidence level. To ensure robust analysis, the sample size was rounded to 60. The estimated standard deviation of the outcome variable based on previous literature was 10. he minimum clinically significant difference or effect size that you want to detect between the two groups = 5.

Methodology:

Data were collected through direct observations, interviews, and systematic reviews, with tools such as detailed clinical examination and standardized assessment protocols.

Patients were evaluated preoperatively through detailed history-taking, clinical examinations, and investigations, including complete hemogram, viral markers, and COVID-19 tests. Written informed consent was obtained from all participants. Surgeries were performed under spinal, saddle, or general anesthesia, as per patient requirements. Postoperative pain was assessed using the Visual Analogue Scale (VAS) at 24 hours, and on postoperative days 3, 7, and 15. Early postoperative complications, such as urinary retention, reactionary hemorrhage, and fever, were recorded within 48 hours. Late complications, including secondary hemorrhage, anal stenosis, recurrence, incontinence, and delayed wound healing, were assessed at one month and three months post-surgery.

Statistical Analysis: Economic impact was evaluated by analyzing hospital stay duration and return-to-work timeline. Data analysis employed descriptive statistics, Results were expressed using numbers, percentages, and measures of central tendency, ensuring both clinical and statistical rigor. Unpaired t-test was used for continuous variables, whereas Fisher’s exact test or chi-square test was used for categorical variables with significance set at p<0.05.

Table 1 compares baseline characteristics between patients undergoing stapled haemorrhoidectomy and conventional haemorrhoidectomy. The mean age was similar between groups (48.23 vs. 53.57 years, p=0.252), with a higher proportion of females in both (73.3% vs. 63.3%, p=0.405). Preoperative hemoglobin levels were comparable (13.49 vs. 13.39 g/dL, p=0.640). Most patients had Grade 3 haemorrhoids (61.7%), with no significant differences in haemorrhoid severity distribution (p=0.959).

Table 1: Demographics and Preoperative Data

Table 2 presents intraoperative and postoperative recovery metrics. Stapled haemorrhoidectomy had a significantly shorter operative time (22.27 vs. 25.00 minutes, p<0.001), less blood loss (30.47 vs. 78.30 mL, p<0.001), shorter hospital stays (1.53 vs. 2.77 days, p<0.001), and faster return to work (5.2 vs. 15.4 days, p<0.001) compared to conventional haemorrhoidectomy.

Table 2: Operative and Hospitalization Data

Early complications, including pain scores and minor adverse events, are compared. Stapled haemorrhoidectomy resulted in significantly lower pain scores on postoperative days 1, 3, and 7 (p<0.001). Rates of urinary retention (10.0% vs. 23.3%, p=0.166), reactionary hemorrhage (3.3% vs. 3.3%, p=1.000), and fever (3.3% vs. 6.7%, p=0.550) were similar between groups [Table 3].

Table 3: Early Postoperative Complications

Late complications were less frequent with stapled haemorrhoidectomy. While secondary hemorrhage (0.0% vs. 3.3%, p=0.236) and anal stenosis (0.0% vs. 6.7%, p=0.092) did not reach significance, delayed wound healing was significantly higher in conventional haemorrhoidectomy (0.0% vs. 13.3%, p=0.016) [Table 4].

Table 4: Late Postoperative Complications

Anaesthesia preferences varied between groups, with saddle block more common in stapled haemorrhoidectomy (40.0% vs. 16.7%) and spinal anesthesia more frequent in conventional haemorrhoidectomy (56.7% vs. 33.3%). General anesthesia use was equal (26.7% in both, p=0.096) [Table 5].

Table 5: Types of Anesthesia Used

Table 6 consolidates significant findings, highlighting advantages of stapled haemorrhoidectomy: shorter operative time, reduced blood loss, faster recovery, lower pain scores, and fewer late complications (notably delayed wound healing, p=0.016).

Table 6: Summary of Key Outcomes

Haemorrhoidectomy is a common surgical procedure for advanced haemorrhoids (Grades 3–4), with conventional techniques like the Milligan-Morgan or Ferguson method involving direct excision of haemorrhoidal tissue. While effective, these procedures often result in significant postoperative pain due to the highly sensitive anoderm and open wounds.6 In contrast, stapled haemorrhoidopexy offers a less traumatic alternative by using a circular stapler to resect redundant rectal mucosa above the dentate line—a region with fewer pain receptors [7]. This fundamental difference in surgical approach underlies the observed variations in outcomes between the two techniques.

Clinically, the study’s findings highlight several key advantages of stapled haemorrhoidectomy. The significantly shorter operative time (22.27 vs. 25.00 minutes) and reduced blood loss (30.47 vs. 78.30 mL) enhance surgical efficiency and patient safety. These benefits translate into practical advantages, such as decreased anesthesia exposure and lower transfusion requirements. Moreover, the shorter hospital stay (1.53 vs. 2.77 days) and quicker return to work (5.2 vs. 15.4 days) underscore the economic and social benefits of the stapled technique, making it particularly appealing for active individuals seeking minimal disruption to their daily lives.

Pain management is another critical area where stapled haemorrhoidectomy excels. The markedly lower Visual Analog Scale (VAS) pain scores at all measured intervals (Days 1, 3, and 7) reflect the procedure’s gentler approach to tissue handling. Reduced postoperative pain not only improves patient satisfaction but also decreases reliance on opioids, mitigating the risks of dependency and side effects. This advantage is further supported by the lower incidence of early complications such as urinary retention, which was nearly twice as common in the conventional group (23.3% vs. 10.0%).

Beyond the immediate postoperative period, stapled haemorrhoidectomy demonstrates superior long-term outcomes. The absence of delayed wound healing in the stapled group (0% vs. 13.3%) is particularly noteworthy, as this complication can lead to prolonged discomfort and additional interventions. Similarly, trends toward fewer cases of anal stenosis (0% vs. 6.7%) suggest better preservation of anal function with the stapled technique. These findings align with the growing emphasis on minimally invasive procedures that prioritize both efficacy and patient comfort.

The choice of anesthesia also reflects the differing demands of each technique. The higher use of saddle block in stapled haemorrhoidectomy (40.0% vs. 16.7%) may be attributed to the procedure’s less invasive nature, which allows for effective regional anesthesia without the need for general sedation. This preference not only reduces perioperative risks but also aligns with modern trends toward opioid-sparing anesthesia protocols.

Consistent with multiple prior studies, our data confirmed that stapled haemorrhoidectomy offers superior operative efficiency. Similar to Bikhchandani et al. (2005) and Hetzer et al. (2002) [8, 9], we observed significantly shorter operative times (22.27 vs. 25.00 min, p<0.001) and reduced blood loss (30.47 vs. 78.30 mL, p<0.001). These findings reinforce the technical advantages of the stapled approach, likely due to its avoidance of extensive tissue dissection and manual vessel ligation. Additionally, our results on hospital stay (1.53 vs. 2.77 days, p<0.001) and return to work (5.2 vs. 15.4 days, p<0.001) closely mirror those of Shukla et al. (2018) and Sudhir et al. (2014) [10, 11] further validating the procedure's role in facilitating rapid recovery.

The marked reduction in postoperative pain with stapled haemorrhoidectomy, evidenced by significantly lower VAS scores at all measured intervals, echoes findings from Khan et al. (2020) and Bikhchandani et al. (2005) [8, 12]. This consistency across studies underscores the anatomical rationale for PPH: by resecting mucosa above the dentate line, the procedure minimizes trauma to pain-sensitive anal tissue. Our low rates of urinary retention (10.0% vs. 23.3%) and absence of reactionary hemorrhage (3.3% in both groups) align with the broader literature, suggesting that stapled techniques may reduce early morbidity without increasing specific risks like bleeding.

While our study reported favorable late complications (e.g., 0% delayed wound healing vs. 13.3%, p=0.016), it contrasts with Jayaraman et al.'s (2007) systematic review, which found conventional haemorrhoidectomy superior in preventing long-term recurrence and prolapse [13]. This discrepancy may reflect differences in follow-up duration (our study's follow-up was shorter than the 1–4 years in Jayaraman’s review) or variations in surgical technique. Shukla et al. (2018) similarly noted higher recurrence with stapled procedures (12% vs. 4%) [10], suggesting that mucosal resection alone may inadequately address underlying vascular pathology in some patients. Our lack of recurrence cases may stem from strict patient selection (primarily Grades 3–4 haemorrhoids) or technical precision, but longer follow-up is needed to confirm durability. The predominance of saddle block anesthesia in our stapled group (40.0% vs. 16.7%) aligns with Bikhchandani et al.'s (2005) emphasis on PPH as a day-care procedure.8 The reduced pain and faster recovery associated with stapled techniques likely contribute to higher patient satisfaction—a trend also reported by Sudhir et al. (2014) (97.6% satisfaction in stapled groups) [11]. However, the choice of anesthesia (spinal vs. general) did not significantly impact outcomes in our study, unlike in some earlier trials where anesthesia type influenced pain perception.

Collectively, these comparisons solidify stapled haemorrhoidectomy’s role as a preferred option for short-term outcomes: less pain, faster recovery, and fewer early complications. However, the long-term efficacy debate, particularly regarding recurrence, remains unresolved. While our data and studies like Khan et al. (2020) support PPH’s safety, Jayaraman et al.'s (2007) findings caution against overestimating its durability [12, 13]. This dichotomy suggests that patient selection (e.g., haemorrhoid grade, prolapse severity) and surgeon expertise may critically influence outcomes. Future studies should standardize follow-up periods and recurrence definitions to clarify these disparities.

In conclusion, this study provides robust evidence supporting stapled haemorrhoidectomy as a superior option for managing advanced haemorrhoids. Its advantages—ranging from shorter operative times and reduced blood loss to faster recovery and fewer complications—make it a compelling choice for both surgeons and patients. While long-term studies on recurrence rates and cost-effectiveness would further solidify its role, the current findings strongly advocate for the adoption of stapled haemorrhoidectomy in clinical practice, particularly for patients seeking a less painful and more efficient surgical experience

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