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Early Experience with Stapled Hemorrhoidopexy in Nairobi, Kenya

Otieno ES1, Mutai KK2

  1. School of Medicine, University of Nairobi

  2. Partnerships in Advanced Care and Treatment, University of Nairobi

Correspondence to: Dr. Edwin S.Otieno, P. O. Box 5510-00100 GPO, Nairobi. Email: oedwin6@hotmail.com

Abstract

Background: Conventional hemorrhoidectomy (CH) is considered the gold standard in the surgical management of symptomatic hemorrhoids. It is however painful and has a relatively lengthy convalescence period. In the last two decades circular mucosectomy using a standard circular stapler has increasingly been performed to mitigate the immediate and short term post-operative shortcomings associated with CH. Methods: A retrospective study of the patients undergoing stapled hemorrhoidopexy in four private hospitals between December 2009 and February 2011 was carried out. The objective was to report our early experience with stapled hemorrhoidopexy (SH) and document treatment outcome regarding post-operative pain score, length of hospital stay, return to normal activity, treatment complications and patient satisfaction. Results: Forty five (45) patients with grade III (8.9%, n=4) and grade IV (91.1%, n=41) hemorrhoids underwent SH during the study period. The mean age was 33.3 (17-54) years with 28 (62.2%) males. The mean pain score at the time of discharge using the visual analog scale (VAS) was 4 (2-5). The mean hospital stay in days was 1.9 +/- 0.6. One patient developed sepsis while two (4.5%) had technical failure of the procedure necessitating conventional excisional hemorrhoidectomy under a different surgeon within 8 months of SH. Two thirds (n=30) were very satisfied, 12 (26.7%) were satisfied and 2 (4.4%) were not satisfied with the procedure. The mean overall satisfaction was 85.2% (sd +/- 20.3). Conclusion: SH is a safe, convenient and effective treatment of hemorrhoids with a high rate of patient satisfaction.

Key Words: Stapled, Hemorrhoidopexy, Outcome, Kenya

Introduction

Hemorrhoidal disease is considered a very common condition worldwide with a wide incidence range between 4 and 86% depending on whether one is concerned with symptoms, anatomic considerations or take-up of care (1). It is estimated that worldwide 50% of the population over 50 years of age have experienced symptoms of hemorrhoids at least once in their life (1,2). Many treatment modalities have been employed in the surgical management of symptomatic hemorrhoids but conventional hemorrhoidectomy (CH,) whether open (Milligan-Morgan), or closed (Furgeson) remains the gold standard against which other procedures must be compared (2,3). These conventional procedures are however known to cause considerable post operative pain, disproportional morbidity for the seemingly benign condition they are supposed to treat and have a relatively lengthy convalescent period (4,5). For two decades now circumferential mucosectomy as conceived by Antonio Longo in 1993 using a standard circular stapler device (PPH03) is increasingly being performed across the world to mitigate some of the shortcomings mentioned above (2). Many studies have indicated that SH considerably reduces postoperative pain (4-10), shortens hospital stay (3, 5-8, 11), shortens operative time (3, 4, 6-8), shortens time to return to normal activity (3-8), and that it is safe (3,5, 6, 8), effective (5) and reproducible (10) with a high patient satisfaction(8). However evidence has emerged to suggest that SH has a higher rate of recurrence of hemorrhoidal symptoms compared to CH (6,12,16)

Methods

This study was conducted in patients admitted at The Nairobi,The Aga Khan, The Mater and MP Shah hospitals which are four leading private institutions in Nairobi, Kenya. Records of all patients who underwent stapled hemorrhoidopexy (SH) and were admitted at the four hospitals between the 1st of December 2009 and the 28th of February 2011 were reviewed. The stapling procedure in each case was done by the same surgeon. Each patient received standard post operative analgesia which comprised initially of an injectable non steroidal anti inflammatory drugs (NSAIDS) in combination with perfalgan and/or pethidine and ultimately was discharged on a combination of a NSAID and BetapynTM or TramalTM. Patients were also discharged on oral laxatives. Patients’ demographic, relevant clinical and operative data was extracted and entered into a standard questionnaire. In addition each patient was directly contacted by phone by the primary surgeon and relevant outcome data obtained. The primary outcomes were postoperative pain, length of hospital stay, return to normal activity, post operative complications, recurrence of symptoms and overall patient satisfaction. Post operative pain was assessed using the verbal numerical rating scale from 1 to 10, where 1 denoted no pain and 10 denoted maximum pain. Return to normal activity was considered as time in days taken for one to resume their usual socioeconomic activities with minimal or no assistance.

Results

A total of 45 patients, majority (62.2%) of them male, underwent SH during the study period. The mean age of presentation was 33.3 (17-54) years. General anesthesia was used in 42 (93.3%) patients while the remaining 3 (6.7%) had spinal anesthesia. Lithotomy position was utilized in 43 (95.6%) and prone position in two patients. The distribution of the cases as per the hospitals is shown in Table 1. Two patients had previously undergone conventional hemorrhoidectomy and one had been managed with banding. Four (8.9%) patients had grade III and 41 (91.1%) had grade IV hemorrhoids. In addition 9 (20%) patients presented wi