Guidance
Current evidence on the safety and efficacy of circular stapled haemorrhoidopexy appears adequate to support the use of the procedure, provided that normal arrangements are in place for consent, audit, and clinical governance.
Clinicians wishing to learn circular stapled haemorrhoidopexy should be trained, mentored, and monitored as described in the Association of Coloproctology’s consensus document on the procedure.
The Procedure.
Indications
Circular stapled haemorroidopexy is used to treat internal haemorrhoids, which develop when cushions of vascular tissue in the anus undergo pathological change. Haemorrhoids may prolapse and cause bleeding, faecal soiling, itching, and occasionally pain.
Outline of the procedure
In circular stapled rectal haemorrhoidopexy, a stapler is used to excise an annulus of rectal mucosa above the haemorrhoids. This reduces the size of internal haemorrhoids by interrupting their blood supply, and reducing the available rectal mucosa with the potential to prolapse. By contrast, conventional surgical haemorrhoidectomy involves excision of haemorrhoidal tissue, anoderm, and perianal skin.
Efficacy
The studies suggested that patients had less pain and returned to normal activity more quickly after stapled haemorroidopexy than after conventional haemorrhoidectomy. In one randomised controlled trial with 84 patients, the average time of return to work was 6 days after the circular stapled technique, compared with 15 days after conventional surgery. For more details refer to the sources of evidence below.
The Specialist Advisors stated that circular stapled haemorroidopexy was relatively new, but that an increasing number of surgeons were using this approach. The Advisors considered stapled haemorroidopexy to be as effective as the surgical alternative. They noted that there were limited long-term data, and that the durability of the procedure was therefore unclear.
Safety
The studies suggested a lower overall postoperative complication rate with circular stapled haemorroidopexy than with conventional haemorrhoidectomy. A systematic review published in 2001 indicated a significant reduction in the risk of bleeding during the first 2 weeks after the procedure. For more details refer to the sources of evidence below.
The Association of Coloproctology’s consensus document stated that adverse events were related to the possibility of a full thickness excision to the rectal wall, with the potential for injury to the internal anal sphincter. In addition, stretching of the anal sphincter by the stapler head may, in theory, cause injury.
The Specialist Advisors suggested that most of the safety concerns were theoretical, and that many of these were not supported by the trials that have been published.
