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Opinioni a confronto in coloproctologia LONGO o MILLIGAN-MORGAN?

Opinioni a confronto in coloproctologia LONGO o MILLIGAN-MORGAN?. Angelo Stuto S.O.C. Chirugia Generale 2 Az. Osp. “S.M.A.” Pordenone. Conclusion. Hemorrhoidal Disease is Caused by Prolapse PPH treats Hemmorhoids by Fixing the Prolapse

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Opinioni a confronto in coloproctologia LONGO o MILLIGAN-MORGAN?

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  1. Opinioni a confronto in coloproctologiaLONGO o MILLIGAN-MORGAN? Angelo Stuto S.O.C. Chirugia Generale 2 Az. Osp. “S.M.A.” Pordenone

  2. Conclusion • Hemorrhoidal Disease is Caused by Prolapse • PPH treats Hemmorhoids by Fixing the Prolapse • PPH is Less Painful and Better Respects the Anatomy and Physiology when compared to Hemorrhoidectomy

  3. Fixes Prolapse Rubber Band Ligation Doppler (?) No Doppler techniques PPH Does not Fix Prolapse Milligan-Morgan Ferguson Parks Laser Cryotherapy ……etc…… Hemorrhoidal Treatments

  4. Longo primi anni ‘90

  5. PPH – The Past • Stapled haemorrhoidopexy (PPH) Longo, A:Treatment of haemorrhoidal disease by reduction of mucosal and haemorrhoidal prolapse with a circular stapling device: a new procedure Proceedings of the 6thWorld Congress of Endoscopic Surgery, Rome 1998 • 2001: 2 small RCTs • Mehigan et al Lancet 2000; 355: 782-5 • Roswell et al Lancet 2000; 355: 779-81 • Short term benefits • Shorter hospital stay • Less postoperative pain • Earlier return to normal function

  6. PPH – The Past • 2000 Disaster! • St Marks RCT • Persistent pain and faecal urgency after stapled haemorrhoidectomy • Lancet 2000; 356: 730-3 • Case reports • Life threatening perianal sepsis • PPH abandoned in many centers mainly in UK

  7. NICE & PPH • NICE review 2006 • Independent analysis by Health Economics Unit, University of York • Meta-analysis • 27 RCTs • 2279 patients

  8. Results: operating time • 17 trials (89%) reported shorter operating time with PPH • Mean op time PPH: 9 – 35.4min • Mean op time CH: 11.5 – 53min • Significant heterogeneity prevented meta-analysis

  9. Results: hospital stay • 14 trials (88%) reported shorter hospital stay with PPH • Mean hosp stay PPH: 0.75 – 5.8days • Mean hosp stay CH: 0.92 – 11.2days • Significant heterogeneity prevented meta-analysis

  10. Results: return to normal activity • 14 trials (93%) reported quicker return to normal activity with PPH • 10 trials significant • Mean time PPH: 6.1 – 23.1days • Mean time CH: 9.8 – 53.9days • Significant heterogeneity prevented meta-analysis

  11. Results: pain • Short-term: less pain following PPH • Long-term: few patients; no difference

  12. Results: bleeding • Short-term: no difference (OR 0.86; 95% CI: 0.46, 1.61; p=0.63) • Long-term: no difference: (OR 1.00; 95% CI: 0.33, 3.01; p=1.00)

  13. Results: complications • No difference in short-term or long-term • Anal stenosis/stricture • Incontinence • Faecal urgency • Urinary retention • Septic complications

  14. PPH & Prolapse

  15. PPH: procedure costs PPH device costs offset by reduced length of stay

  16. NICE Recommendation 2007 “Stapled haemorrhoidopexy, using a circular stapler specifically developed for haemorrhoidopexy, is recommended as an option for people in whom surgical intervention is considered appropriate for the treatment of prolapsed internal haemorrhoids”.

  17. Consideration on the metanalysis results • “Low Power”= small pts’ cohort • PPH Learning curve vs well known “old” technique • Small number of Italian patients • How prolapse is evaluated? • Is the outcome comparator the same for the 2 techniques?!

  18. PPH vs MMH (metanalisi) • PPH vs. MM better for (Pain, recovery, incontinece, stenosis, bleeding etc) • PPH vs MM worst for prolapse recurrence but there is no significativity when re-surgery is considered

  19. Recurrent Prolapse following PPH Aetiology • ? Role of anal skin tags • ? Learning Curve • ? Residual prolapsing haemorrhoids • PPH resection limited by stapler housing • ? De novo prolapse Schwandner et al Coloproctology 2006; 28: 13-20 • 16% patients with prolapsing haemorrhoids will have symptoms of obstructed defaecation • Internal rectal prolapse & rectocele

  20. Distal Rectal Redundancy Rectocele Internal prolapse Haemorrhoids with Internal prolapse

  21. PPH & Obstructed Defaecation • All patients presenting with prolapsing piles should be carefully evaluated for coexistent obstructed defaecation • Investigation should include defaecatory proctography • Consideration given to PPH-STARR (STARR for Haemorrhoids) • Combined treatment of piles and internal rectal prolapse

  22. F. Hetzer, A. Senagore in Transanal Stapling approach for anorectal prolapse ed. Springer 2009

  23. SUMMARY • Initial concerns regarding PPH have largely been resolved • Benefits • Shorter hospital stay • Less pain • Quicker recovery • Disadvantage • Increased rate of recurrent prolapse • Spectrum disease • haemorrhoids --- internal rectal prolapse • PPH-STARR may be the preferred treatment option

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