Table 5: Stapled versus open haemorrhoidectomy


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


(Basdanis 2005)


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)


(Bikhchandani 2005)


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)


(Boccasanta 2001)


LoE 1


 


Modified open Milligan Morgan haemorrhoidectomy (Hospital Leopold Bellan
(HLB) technique) versus stapled circumferential mucosectomy (Longo’s)


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)


(Brown 2001)


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


(Cheetham 2003)


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


(Chung 2005)


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)


(Ganio 2001)


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


(Gravie 2005)


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)


(Helmy 2000)


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


(Kairaluoma 2003)


LoE 1


Conventional open haemorrhoidectomy with diathermy dissection and
without pedicle ligation, plus intra-op infiltration with 5–10 ml lidocaine 0.5% + epinephrine 1:200,000 versus stapled haemorrhoidectomy by means of the PPH01 stapling device


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


 


(Kraemer 2005)


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


(Krska 2003)


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)


 


(Mehigan 2000)


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
10 mg (2 tablets three times a day orally as required, for 1 week) and local 0·2% glyceryl trinitrate (to anal margin three times a day for 14 days)


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


(Ortiz 2002)


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)


(Ortiz 2005)


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


 


(Palimento 2003)


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


(Pavlidis 2002)


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


(Rowsell 2000)


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)


(Shalaby 2001)


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