In this study, long-term results showed that the hemorrhoid recurrence rates in the C-PSH and CSH groups were similar, and constipation was an independent prognostic factor for recurrence. The C-PSH group had the advantage of reduced fecal urgency, pain during the first bowel movement after surgery, and major complications. However, in the C-PSH group, the operative time was slightly longer and the vertical length of the rectal mucosal specimen was shorter than in the CSH group.
Treatment strategies for hemorrhoids include medical and surgical treatments. Surgical treatment is considered the most effective strategy for recurrent or symptomatic hemorrhoids. [2]. However, traditional surgery (such as Milligan-Morgan hemorrhoidectomy) has several disadvantages, including severe postoperative pain and a prolonged recovery period. [15]. Since the anal cushion theory was proposed by Thompson, the treatment of hemorrhoids has changed significantly. [16]. In 1998, Longo first reported a circular staple hemorrhoidopexy (CSH) procedure using a circular suture device to manage hemorrhoid disease by reducing mucosal and hemorrhoidal prolapse. [7]. We observed that compared with traditional surgery, using CSH accelerated postoperative recovery and reduced postoperative pain. Since then, CSH has become widely popular. However, many side effects have been reported, including fecal urgency, anal stenosis, heavy bleeding, and other complications. [5, 9, 10, 17]. In recent years, partial stapled hemorrhoidopexy (PSH), which features a specially designed anoscope, has been introduced into clinical treatment and has been reported to reduce the disadvantages of stapled hemorrhoidopexy. [5, 14, 18]. Using this technique, a partial rectal mucosa above the dentate line is excised, preserving the mucosal bridge between the mucosal resection areas. [5, 19]. Compared to CSH, complication rates are significantly reduced and long-term outcomes are comparable [14, 18, 19]. However, PSH equipment, especially specially designed anoscopes, is not available in some areas. As a result, the dissemination of this technology is severely limited. Therefore, we presented a simplified C-PSH technique that utilizes easily accessible instruments (intestinal spatula or tongue spatula) to preserve the rectal mucosal bridge during the performance of stapled hemorrhoidopexy. .
According to our study, the operation time of C-PSH was slightly longer than that of CSH group. It may be due to intestinal spatula placement and “dog’s ear” ligation. Although the vertical length of rectal mucosal specimens was longer in the CSH group, multivariate Cox regression analysis revealed that it was not an independent prognostic factor for hemorrhoid recurrence. Postoperative fecal urgency after CSH has been reported to be as high as 40%. [20]. In this study, the incidence of urgency in the C-PSH group (18.9%) was much lower than that in his CSH group (31.5%). The cause of the urge to defecate is not clear.It was speculated that a foreign object or inflammation in the staple ring might cause such discomfort. [18]. The decreased incidence in the C-PSH group may be interpreted by decreased staple retention and inflammatory response within the staple ring. Postoperative pain is usually inevitable with hemorrhoidectomy. Stapled hemorrhoidopexy significantly reduces postoperative pain compared to traditional hemorrhoidectomy. [8]. It should be noted that Chinese surgeons preferred to excise the skin tags left after stapled hemorrhoidopexy. Here’s why: Skin tags are usually observed after CSH or C-PSH, and the aesthetic requirements of the patient are considered. Additionally, the study demonstrated that postoperative pain was comparable in patients who underwent skin tag removal and those who did not. [5, 21]. In the present study, low levels of postoperative pain were observed in the C-PSH and CSH groups. It was also observed that the first defecation pain in the C-PSH group was lower than that in the CSH group. Reserved rectal compliance in the C-PSH group may have contributed.
Morbidity is one of the efficient indicators to evaluate the safety of a technique. In this study, the incidence of serious complications in the C-PSH group was observed to be lower than in the her-CSH group. Three of her patients in the CSH group and her one patient with insufficient mucosal crosslinking in the C-PSH group developed massive bleeding. We hypothesized that the main cause is that the anastomotic stoma is subjected to excessive tension during defecation. Rectal stenosis is one of the common postoperative complications of stapled hemorrhoidopexy and usually occurs within 4 months postoperatively. [22]. No patients in the C-PSH group suffered from stenosis, but four patients in the CSH group experienced this complication during follow-up.The results are consistent with previous studies [5, 14]. It was thought that excessive annular fibrosis around the staple might be the cause of the stenosis. The secured mucosal bridge maintains rectal compliance and significantly reduces the incidence of rectal stenosis in the C-PSH technique. Chronic anal pain was observed in three of her patients. Two patients were in the CSH group and one patient was in the C-PSH group. All three patients were observed to retain their staples. Discomfort was reduced by removing the exposed staples.It is thought to be caused by persistent inflammation and excessive fibrosis. [18, 23, 24].
The 5-year recurrence rate (12.9%) and cumulative recurrence rate (19.9%) in the C-PSH group were higher than in the CSH group, but the differences were not significant. The recurrence rate in this study was lower than that reported in previous studies. Tjandra et al. reported that the recurrence rate of hemorrhoidal disease after CSH was 25%. [6].Constipation is considered a risk factor for the development of hemorrhoids [2, 25]. Multivariate Cox regression analysis revealed that constipation was an independent prognostic factor for hemorrhoid recurrence. Therefore, managing constipation is an effective means of reducing the likelihood of hemorrhoid recurrence.
Although C-PSH has many advantages in the treatment of hemorrhoids, its disadvantages should not be ignored. One disadvantage is that a large portion of the staples remains after stapled hemorrhoidopexy, which can cause metal artifacts on magnetic resonance examinations. [24]. Also, the general trauma is more severe than other treatments such as rubber band ligation. Therefore, many surgeons tend to adopt other techniques to alleviate hemorrhoid disease. Recognizing the potential weaknesses, hemorrhoidopexy with stapling was limited to patients with grade IV hemorrhoids in our team. Based on our C-PSH practices, we would like to share some preliminary experiences with operators. First, the insertion position of the spatula is not constant. The surgeon can select the hemorrhoid space as the insertion point. Second, applying Parolin to the spatula makes insertion easier. Third, the insertion procedure should be performed carefully and slowly to avoid anal fissures and mucosal damage.
Our study has several limitations. First, all cases were from local Chinese patients, and whether C-PSH is superior to CSH surgery needs to be further validated in other populations. Additionally, lifestyle changes (such as eating habits and bowel habits) cannot be controlled and may affect long-term surgical outcomes. Furthermore, this study serves as a preliminary investigation of his C-PSH technique and aims to showcase its accessibility. This is a single-center study with a small sample size and a retrospective design. As a non-randomized controlled trial, this approach may introduce bias and compromise the quality of the results. Although we employed propensity score matching (PSM) to reduce confounding bias, it cannot completely replace randomized controlled trials. In the near future, it will be essential to conduct multicenter, large-scale, randomized, long-term studies to provide more robust evidence.