The comparison of an accessible C-shaped partial stapled hemorrhoidopexy (C-PSH) versus circular stapled hemorrhoidopexy (CSH) in patients with grade IV hemorrhoids: a retrospective cohort study

Consecutive patients, diagnosed with grade IV hemorrhoids, consented circular stapled hemorrhoidopexy or C-shaped partial stapled hemorrhoidopexy in the Department of Colorectal Surgery of Hangzhou Third People’s Hospital between January 2016 and June 2017 were obtained from electronic medical record system. The patients were informed the details of the two techniques and had the privilege of choosing one. Patients with severe diseases (cardiovascular diseases or cerebrovascular diseases), abnormal coagulation, colorectal diseases (thrombosis hemorrhoids, anal fistula, abscess, stenosis, inflammatory bowel disease and tumor), and age less than 18 years were excluded. The baseline characteristics including gender, age, body mass index (BMI), self-reported hemorrhoids duration and defecation situations (chronic diarrhea or constipation) were collected. Chronic diarrhoea was diagnosed when patient met the following criteria: stool consistency between types 5 and 7 on the Bristol stool chart and duration greater than 4 weeks [11]. The diagnosis of chronic constipation was referred to the functional constipation of Roma IV criteria [12].

All patients had a routine bowel-cleansing enema before surgery. After spinal anesthesia, the patients were placed in the prone Jack-knife position. Both the C-PSH and CSH procedures were conducted by the same group of doctors, all of whom possess over 25 instances of experience in performing C-PSH and CSH procedures. In the C-PSH group, a disposable stapler kit (PSHS34, Victor, China) combined with an accessible intestinal spatula (Fig. 1) were used for performing the C-PSH. After a routine anal dilatation, anal physical examination was performed to confirm hemorrhoidal positions and spaces between hemorrhoids (Fig. 2a). An anoscope was inserted through the anal canal and fixed. Then, a hemorrhoidal space was selected as an insertion point, and the intestinal spatula was carefully placed through the gap between the anal canal and anoscope (Fig. 2b). The top of the intestinal spatula reached 5 cm above the dentate line. A pursestring was placed approximately 3 cm above the dentate line by a 2–0 suture (Vicryl Plus, ethicon, USA), and the depth of suture within submucosa. Because of the intestinal spatula, the shape of pursestring was similar to alphabet “C”. The anvil of stapler was introduced and positioned above the C-shaped pursestring, and the suture was then secured to the rod (Fig. 2c). C-shaped mucosal flap was pulled into the barrel of the stapler, and the stapler was fired. A vaginal examination was routinely performed before stapler was fired in sexually active women patients. After removing stapler and intestinal spatula, a stapler bridge connecting the mucosectomies was formed and normal mucosal bridge was under it. The stapler bridge was then separated, “dog ears” were ligated by 3–0 suture (Vicryl Plus, ethicon, USA) (Fig. 2d). A routine inspection of anastomotic stoma was performed and anastomotic bleeding was controlled by using “8” suture. Perianal appearance after C-shaped partial stapled hemorrhoidopexy was shown in Fig. 2e. Finally, the residual skin tags were removed routinely after C-PSH procedure. The resected C-shaped specimen was shown in Fig. 2f. In the CSH group, the disposable hemorrhoids stapler kit (PSHS34, Victor, China) was also used for performing stapled hemorrhoidopexy as the method described by Longo [7]. After CSH procedure, the remaining external piles were also routinely excised. Postoperative managements including nursing care, dietary adjustments, and sitz baths, and postoperative analgesia were standardized.

The primary outcome was the five-year recurrence rate of hemorrhoids. Secondary outcomes included intraoperative outcomes, postoperative outcomes and complications. Intraoperative outcomes including operation duration, blood loss, vertical length of resected mucosa specimen and skin tags resection were collected. Operation time was recorded from disinfection to dressing. Blood loss was estimated by the same specification gauze (each gauze was represented as 5 ml). Specimens were routinely examined by the same group of pathologists. Postoperative outcomes included postoperative pain, fecal urgency and hospital stay. Postoperative pain was assessed by NRS (numeric rating scale, scores from 0 to 10; 0 as painless and 10 as worst pain) [13]. NRS scores were recorded at 1^st day, 2^nd day, 3^rd day, 7^th day and first defecation after surgery. Fecal urgency was defined as unable to defer defecation for more than 15 min [5]. Complications such as urine retention, haemorrhage, perianal abscess, rectal or vaginal fistula, rectal stenosis, and chronic anal pain were recorded.

The follow-up lasted until September 2022. In the first year, patients were routinely assessed by experienced colorectal surgeons at 1 week, 1 month, 3 months, 6 months and 1 year after surgery. Then, the follow-up was performed once a year. The follow-up visits included outpatient visit and telephone interview. During outpatient visits or telephone interviews, patients were queried about symptoms of hemorrhoids, such as painless bright red bleeding, prolapsing hemorrhoids, soiling, pain, itching, or any combination of these symptoms. Unless the patient was completely asymptomatic, they would be scheduled for a follow-up examination in the outpatient clinic. Any discomfort not limited to chronic anal pain, rectal stenosis and recurrence was recorded and received appropriate treatment. Recurrence is defined as at least one symptom recrudesce after 2 months symptom-free period and confirmed by an experienced colorectal surgeon [14].

A total of 256 patients met the inclusion criteria in the present study. Among the 256 patients, 122 (47.7%) underwent C-PSH, and 134 (52.3%) underwent CSH. After propensity score matching, a total of 222 patients were ultimately enrolled, with 111 in the C-PSH group and 111 in the CSH group (Fig. 3). A good balance was achieved, and the clinical features were shown in Table 1.

The operation time in the C-PSH group was slightly longer than that in the CSH group (C-PSH vs. CSH, median 23 min vs. 21 min, p < 0.01). The vertical length of rectal mucosa specimen was shorter in the C-PSH group (C-PSH vs. CSH, 3.11 ± 0.58 cm vs. 3.42 ± 0.43 cm, p < 0.01). There were no significant differences in estimated blood loss, skin tags resection, urine retention, and hospital stay between the two groups (p > 0.05) (Table 2).

The fecal urgency incidence in the C-PSH group was lower than that in the CSH group (C-PSH vs. CSH, 18.9% vs. 31.5%, p = 0.03) (Table 2). Compared with the CSH group, the NRS score in the C-PSH was lower than that in the CSH group at first defecation after surgery (C-PSH vs. CSH, 3.07 ± 1.60 vs. 3.68 ± 1.56, p < 0.01) (Fig. 4a). However, the pain scores in 1^st, 2^nd, 3^rd and 7^th postoperative days between the two groups were comparable (all p > 0.05) (Fig. 4b)

The median follow-up of this study were 70 months (24–79 months) in the C-PSH group and 68 months (16–80 months) in the CSH group. There were 14 (6.3%) patients lost to follow-up: 6 (5.4%) in the C-PSH group and 8 (7.2%) in the CSH group. One elder patient in the CSH group died from a severe pneumonia at 16 months after surgery, and the other patients dropped out of the study or lost contact. A total of 31 patients were confirmed hemorrhoidal recurrence: 18 (16.2%) in C-PSH group and 13 (11.7%) in CSH group. The five-year recurrence rates between the C-PSH group and CSH group were comparable (12.9% vs. 9.4%, hazard ratio = 1.43, p = 0.38). There was also no significant difference in the cumulative recurrence rate between the two groups (C-PSH vs. CSH, 19.9% vs. 14.7%, hazard ratio = 1.39, p = 0.37, Fig. 5). Among the recurrence patients, two patients with CSH and two cases with C-PSH underwent conventional hemorrhoidectomy due to significant prolapse and bleeding, and one patient with CSH due to pronounced bleeding and mild prolapse received rubber band ligation. The remaining patients were relieved by conservative treatments.

The results showed that constipation was an independent prognostic factor (hazard ratio, 4.48, 95%CI: 1.99–10.05, p < 0.01). The operative modality was not a risk factor that contributed to the hemorrhoidal recurrence (hazard ratio, 1.60, 95% CI: 0.76–3.37, p = 0.22) (Table 3).

Major postoperative complication rate in the C-PSH group was significantly lower than that in the CSH group, (C-PSH vs. CSH, 1.8% vs. 8.1%, p = 0.03) (Table 2). Nine patients suffered postoperative complications in the CSH group: 3 (2.7%) with massive hemorrhage, 4 (3.6%) with rectostenosis, and 2 (1.8%) with chronic anal pain. Two patients experienced postoperative complications in the C-PSH group: 1 (0.9%) with massive hemorrhage and 1 (0.9%) with chronic anal pain. Three patients in the CSH group with major postoperative complications required surgical treatments: two patients with rectostenosis and one patient with massive hemorrhage. One patient with C-PSH group suffered massive hemorrhage and was treated with surgery. The other patients were relieved by conservative treatments.