Table 5: Stapled versus open haemorrhoidectomy
Study | Comparison | n stapled/ open | Supplemental analgesia | Pain scores and type if specified | Use of supplemental analgesia | Other pain outcome | Functional outcomes | Other important outcomes |
LoE 1 | Open haemorrhoidectomy according to the Milligan-Morgan technique and using Ligasure, versus stapled haemorrhoidectomy, performed with a circular stapling device | 50/45 | Rescue analgesia was IV diclofenac | VAS pain scores: stapled superior at 8 and 24 h (both p<0.01). Pain scores on stool evacuation: stapled superior at 24 h (p<0.001), NS at 1 week | NS analgesic use | Not reported | Wounds fully healed at 1 month: NS Faecal impaction: NS | Intra-operative bleeding: diathermy superior (p<0.05) Postoperative bleeding: NS Pruritus: stapled superior (p<0.001) Urinary retention: NS Incontinence: NS Length of hospital stay: NS Days to return to normal activity/work: stapled superior (p<0.05) |
LoE 1 | Open Milligan Morgan technique versus modified Longo technique (stapled) | 42/42 | Diclofenac 1.5 mg/kg IM was given as required. If there was no response within an hour (as assessed by the patient), an injection of tramadol 2 mg/kg IV was given | VAS pain scores: stapled superior at 12 and 24 h, days 3 (all p<0.001), 7 (p<0.01) and 15 (p<0.001) days. VAS pain at first motion: stapled superior (p<0.001) | IM Diclofenac requirement: stapled superior (p<0.001). IV Tramadol requirement: stapled superior (p<0.034) | More patients had persistent pain at follow-up with open, but no statistics were reported | Time to passage of first motion: NS Incidence of incontinence: NS Incidence of rectal bleeding: NS More patients had unhealed perianal wound at 2 weeks with open, but no stats. | Urinary retention: NS Fever: NS Length of hospital stay: stapled superior (p<0.01) Time to return to work/routine activities: stapled superior (p<0.001) Satisfaction scores: stapled superior (p<0.01) |
LoE 1 | Modified open Milligan Morgan haemorrhoidectomy (Hospital Leopold Bellan | 40/40 | Dexketoprofen 25 mg orally three times a day was used for the first week and 25 mg twice a day for the second week | Number of patients with VAS pain scores >5: stapled superior (p<0.001) | Not reported | Not reported | Haemorrhage, early (within 10 days of op) or late (<1 year after op): NS Incidence of late complications (<1 year postop; stenosis, haemorrhage, soiling): NS | Incidence of urinary retention: NS Hospital stay: stapled superior (p<0.01) Duration of inability to work: stapled superior (p<0.001) |
LoE 1 | Open Milligan Morgan with diathermy versus stapled mucosectomy using standard PPH equipment | 15/15 | IM pethidine and oral NSAIDs | VAS pain scores at rest: open superior immediately postop (p<0.02); stapled superior after 2 weeks (p<0.05). VAS pain scores on bowel motion: stapled superior after 2 weeks (p<0.005), NS immediately postop | NS number of IM pethidine injections immediately postop, NS number of NSAID tables immediately postop and at 2 and 6 weeks. | Number of patients with pain at 6 weeks: stapled superior (p<0.05) | Persistent minor bleeding: stapled superior at 2 and 6 weeks (both p<0.05) Wound discharge at 2 and 6 weeks: NS Stenosis: NS at 6 weeks | Time taken to return to work: stapled superior (p<0.05) Length of hospital stay: NS |
LoE 1 | Standard open diathermy haemorrhoidectomy versus stapled haemorrhoidectomy, using a circular stapler | 15/16 | All patients received diclofenac (50 mg 3 times/day for 1 week), topical 0.2 percent glyceryl trinitrate ointment (3 times/day for 2 weeks), and metronidazole (400 mg 3 times/day for 1 week). In addition, patients were provided with codydramol to be used as required | Total pain score: stapled superior (p=0.027). Maximal pain score: stapled superior (p=0.018). Mean expectation score: stapled superior (p=0.037). NS individually on POD1-10 | Not reported | Not reported | Not reported | Bleeding: NS at 6 weeks or final follow-up Time to return to work: NS Patient satisfaction scores at final follow-up: NS |
LoE 1 | Open haemorrhoidectomy with Harmonic Scalpel™ dissection versus stapled haemorrhoidopexy (Longo’s) | 45/43 | Oral dologesic (2 tablets, 4 x daily as needed), IM pethidine (1 mg/kg every 4 h) for pain relief | Mean VAS pain scores: stapled superior (p=0.002) | NS number of pethidine injections required; NS number of dologesic tablets consumed | Not reported | Time to first bowel movement: NS Intra-operative blood loss: NS | Incidence of urinary retention: NS Length of hospital stay: stapled superior (p=0.02) Time to return to work: stapled superior (p=0.002) Patient satisfaction: stapled superior (p=0.001) |
LoE 1 | Open haemorrhoidectomy according to the Milligan-Morgan technique versus stapled haemorrhoidectomy, performed with a circular stapling device | 47/48 | Nimesulide tablets taken as needed postop, severe pain required IM ketorolac | Cumulative pain score: stapled superior (p=0.03) | NS composite pain score (number of analgesics/number of days of consumption) | Number of days of experiencing moderate (score 4-7) pain: stapled superior (p=0.01). Number of days of experiencing severe (score 8-10) pain: stapled superior (p=0.03) | Incontinence scores: stapled superior (p=0.04) on day 30, NS on day 10. Constipation scores: stapled superior (p=0.02) on day 30 | Length of hospital stay: stapled superior (p=0.01) Time to resume normal activities: stapled superior (p=0.04) Number of days of postop bleeding: NS Haemorrhage: NS Number of patients requiring urinary catheter: NS |
LoE 1 | Open haemorrhoidectomy according to the Milligan-Morgan technique versus stapled hemorrhoidopexy (Longo’s), performed with a circular stapling device | 63/63 | Analgesics were administered on the basis of the VAS score: VAS<3, a WHO class I analgesic (paracetamol); between 3 and 5, a WHO class II analgesic (paracetamol codeine, dextropropoxyphene-paracetamol); or VAS >5, a WHO class III analgesic (morphine administered systematically with paracetamol). Also all patients received 300 mg ketoprofen per day in hospital | VAS pain scores during defecation: stapled superior on days 1–10 (all p<0.001), NS pain scores at rest | Class II analgesic consumption: stapled superior over days 1–3 (p=0.002). NS morphine consumption over days 1–3. Number of patients no longer requiring morphine after 24 h: stapled superior (p<0.01). NS class I consumption | Not reported | Time to first defecation: stapled superior (p=0.006) Topical treatments (wound care management): stapled superior (p<0.001) Fecaloma: stapled superior (p=0.033) Incidence of continence problems and stenosis: NS | Incidence of urinary retention: NS Incidence of postop bleeding: NS Length of hospital stay: stapled superior (p<0.001) Time to resume normal activities: stapled superior (p<0.001) |
LoE 2 | Open haemorrhoidectomy (Milligan-Morgan technique) versus stapled haemorrhoidectomy (Milito’s), performed with a circular stapling device | 20/20 | IV diclofenac 1 mg/kg intra-op. IV morphine 0.1 mg/kg, diclofenac 50 mg orally 3 times daily for 1 week | Average pain scores: stapled superior (no statistics reported) | Not reported | Not reported | Time to first bowel motion: stapled superior (no statistics reported) | Urinary retention: NS (1 patient from each group) Time to return to normal activities: stapled superior (p=0.0002). Length of hospital stay: NS |
(Ho 2000) LoE 1 | Conventional diathermy haemorrhoidectomy versus stapled haemorrhoidectomy by means of a circular stapling device | 57/62 | Ketoprofen tablets (100 mg) or IM pethidine (1 mg/kg) | Pain at stool evacuation: stapled superior (p<0.005) at 2 weeks postop, NS in hospital. NS maximal pain in hospital and at 2 weeks postop | Ketoprofen requirements: stapled superior at 2 weeks (p<0.005) and 6 weeks (p<0.05), NS in hospital. NS IM pethidine requirement in hospital | NS number of patients with persistent pain at 6 week and 3 month follow-up | Number of patients experiencing a bowel movement before discharge: stapled superior (p<0.05) Wounds fully healed at 6 weeks: stapled superior (p<0.05), NS at 3 months. Faecal impaction: NS at 2 and 6 weeks, and 3 months Number of bowel movements per week: NS at 2 weeks, 6 weeks and 3 months Incontinence scores: NS at 6 weeks and 3 months | Minor wound bleeding: stapled superior (p<0.05) at 2 weeks, NS at 6 weeks and 3 months Pruritus: stapled superior (p<0.05) at 2 weeks, NS at 6 weeks and 3 months Time to return to normal activities/work: stapled superior (p<0.05) Length of hospital stay: NS Satisfaction scores: NS in hospital, at 2 and 6 weeks, and at 3 months |
LoE 1 | Conventional open haemorrhoidectomy with diathermy dissection and | 30/30 | Postop analgesia consisted of oral diclofenac 50 mg twice daily supplemented with paracetamol + codeine when necessary | Average pain scores from days 1–14: stapled superior (p=0.0002). Average pain relative to that expected by the patients: stapled superior (p=0.0018) | Diclofenac requirement: stapled superior (p=0.032). NS paracetamol + codeine requirement | Number of patients experiencing pain at 6 weeks and 12 months: NS | Soiling: NS at 6 weeks or 12 months | Early postoperative morbidity (bleeding, fever, stenosis): NS Postoperative bleeding: diathermy superior (p=0.024) at 6 weeks, NS at 12 months Length of hospital stay: NS Time to return to work: NS |
LoE 1 | Open Milligan Morgan haemorrhoidectomy using LigaSure dissection versus stapled haemorrhoidopexy (Longo’s) | 25/25 | Postop analgesia consisted of metamizole (2–3 × 30 drops) and diclofenac (3 × 50 mg) or ibuprofen (3 × 400 mg). Opiates given on demand | NS VAS pain scores days 1–21 | NS postop analgesia requirements | NS pain on defecation at 6 weeks | Time to first defecation: NS | Urinary retention: NS Bleeding: NS immediately postop and at 6 weeks Incontinence: NS at 6 weeks Irritation/itching/moisture: NS Length of hospital stay: NS Patient satisfaction: NS Self-assessment of personal activity: NS up to POD21 and at 6 weeks |
LoE 2 | Open Milligan-Morgan haemorrhoidectomy versus stapled haemorrhoidectomy (Longo’s), performed with a circular stapling device | 25/25 | Not reported | Pain scores: open superior on day 3 and 7 but not on day 1 (no statistics reported) | Not reported | At 1 month, more patients in stapled still had occasional pain (no statistics reported) | Not reported | Length of hospital stay: open superior (no statistics reported) Time to return to work: open superior (no statistics reported) |
(Lau 2004) LoE 1 | Open diathermy haemorrhoidectomy versus stapled haemorrhoidectomy by means of the PPH33 stapling device | 13/11 | Postop oral dologesic tablets and IM pethidine (1 mg/kg) | NS overall pain score for the first 2 days, NS maximum pain scores at rest for the first 2 days, NS maximum pain score on defecation | NS dologesic tablets required, NS total IM pethidine requirement | Not reported | Incontinence score: NS | Urinary retention: NS Postop bleeding: NS Length of hospital stay: stapled superior (p=0.014) |
LoE 1 | Open haemorrhoidectomy (Milligan-Morgan technique) with pre-op infiltration with 20 ml bupivacaine 0.25% + epinephrine 1:200,000 versus stapled haemorrhoidectomy (Milito’s), performed with a circular stapling device | 20/20 | IV diclofenac 1 mg/kg intra-op. IV morphine (0·1 mg/kg IV rescue analgesia in the first 24 h), regular diclofenac (50 mg three times a day orally for 1 week), paracetamol 500 mg + dihydrocodeine | Average pain score over 10 days: stapled superior (p<0.0001). Pain relative to what was expected: stapled superior (p<0.0001) | NS number of opioid injections required | Not reported | Time to first defecation: stapled superior (p=0.02) | Time to resume normal activities: stapled superior (p=0.0002) Length of hospital stay: NS Incidence of urinary retention: NS Patient-assessed satisfaction with symptom control: NS |
LoE 1 | Conventional open diathermy haemorrhoidectomy versus stapled haemorrhoidopexy (Longo’s) by means of a circular stapling device | 27/28 | Dipyrone (575 mg orally 4 x daily) and diclofenac (100 mg orally 2 x daily), and rescue IV tramadol (100 mg 3 x daily) | Mean pain scores during the first 14 days: stapled superior (p<0.007) | NS number of patients requiring IM analgesics | NS persistent pain or incidence of pain at follow-up (>1 year) | Time to first bowel movement: NS Faecal impaction: NS Incontinence: NS at follow-up | Time to return to work activities: NS Urinary retention: NS Secondary haemorrhage: NS Haemorrhage at follow-up: NS Itching: NS at follow-up Patient’s satisfaction scores at follow-up: diathermy superior (p<0.004) |
LoE 1 | Conventional open diathermy haemorrhoidectomy versus stapled haemorrhoidopexy (Longo’s) by means of a circular stapling device | 15/16 | Dipyrone (575 mg orally 4 x daily) and diclofenac (100 mg orally 2 x daily), and rescue IV tramadol (100 mg 3 x daily) | NS mean pain scores during the first 14 days (stapled<diathermy, p=0.05) | NS number of patients requiring rescue analgesia on POD1 | Number of patients with pain at 1 year: NS (n=0/group) | Time to first bowel movement: NS Tenesmus at 1 year: diathermy superior (p=0.007) | Itching: diathermy superior (p=0.03) at 1 year Haemorrhage: NS at 1 year Incontinence: NS at 1 year |
LoE 1 | Open Milligan-Morgan haemorrhoidectomy versus stapled haemorrhoidectomy, performed with a circular stapling device | 37/37 | Parenteral diclofenac for rescue analgesia | VAS pain scores: stapled superior at 4 h (p=0.001) and 24 h (p<0.0001) and after first defecation (p<0.0001) | NS diclofenac consumption | NS incidence of occasional pain at follow-up (10–27 months) | Time to pain-free defecation: stapled superior (p=0.001) | Episodes of bleeding: NS Urinary retention: NS Time to return to normal activities/work: NS |
LoE 1 | Open Milligan-Morgan haemorrhoidectomy versus stapled Longo’s procedure, performed with a circular stapling device | 33/36 | PCEA morphine for on-demand rescue analgesia | VAS pain scores: stapled superior at 3, 6, 12 (all p<0.05) and 24 (p<0.01) h | Consumption of epidural morphine: stapled superior (p<0.01) | Not reported | Not reported | Length of hospital stay: stapled superior (p<0.05) Satisfaction scores: stapled superior (p<0.05). Postop bleeding: NS |
LoE 1 | Conventional open diathermy haemorrhoidectomy plus local injection of 20 ml bupivacaine 0.5% + epinephrine 1:200,000 versus stapled haemorrhoidopexy (Longo’s) by means of a circular stapling device | 11/11 | Patients received 2 x co-codamol tablets up to 4 times daily as needed | Mean total pain score: stapled superior (p=0.003) | NS consumption of co-codamol tablets | Not reported | Not reported | Length of hospital stay: stapled superior (p<0.0001) Time to return to normal activities: stapled superior (p<0.005) |
LoE 1 | Standard open Milligan Morgan haemorrhoidectomy (with pre-op infiltration with 20 ml bupivacaine 0.25% + epinephrine 1:200,000) versus stapled (Longo’s) technique | 100/100 | Pethidine 1.5 mg/kg IV for the first 24 h. Diclofenac 50 mg orally and local lidocaine hydrochloride gel were given as required for 1 week | VAS pain scores: stapled superior during the first 24 h, at the time of the first motion, and at 1 week (all p<0.001) | Number of doses of analgesics per day: stapled superior (p<0.001) | Not reported | Time to wound healing: stapled superior (p<0.001) Anal discharge: stapled superior (p=0.002) Anal stenosis: NS | Postop bleeding: NS Urinary retention: NS Length of hospital stay: stapled superior (p<0.001) Time to resume full activity: stapled superior (p<0.001) |
(Van-de-Stadt 2005) LoE 1 | Open Milligan-Morgan haemorrhoidectomy versus stapled haemorrhoidopexy (Longo’s) | 20/20 | Postop analgesia was standardised and included an association of NSAIDs, paracetamol and eventually narcotic analgesics | VAS pain scores: stapled superior (mean score from POD 0–21) at rest and during defecation (p<0.001) | Not reported | Not reported | Time to complete healing: stapled superior (p<0.0001) Haemorrhage at day 7: NS | Urinary retention: NS Length of hospital stay: stapled superior (p=0.021) Patient’s satisfaction: NS at the end of follow-up |