Procedure for prolapsed haemorrhoids versus excisional haemorrhoidectomy--a systematic review and meta-analysis.
Abstract: Background. The procedure for prolapse and haemorrhoids (PPH) was introduced to address the postoperative pain following excisional haemorrhoidectomy (EH).

Objective. To assess the efficacy of both procedures to treat haemorrhoids.

Data sources. Literature review using MEDLINE. Articles addressing PPH and EH were included.

Study selection. RCTs comparing EH and PPH with =20 patients.

Data extraction. Primary endpoints were pain, operative time, hospital stay, satisfaction with procedure and time to return to normal activity. Secondary endpoints such as recurrence and complications were collated for descriptive analysis. A meta-analysis was performed using the random effects model on studies reporting 'mean' and SD or SEM.

Data synthesis. PPH was associated with less postoperative pain, less operative time, shorter hospital stay and earlier return to normal activities compared with EH. There appears to be no significant difference in satisfaction with the procedure. There was no difference between the two procedures in terms of complications. There were more recurrences after PPH.

Conclusion. Compared with EH, PPH is associated with less postoperative pain, reduced operative time and hospital stay and earlier return to normal activity, and a trend towards improved patient satisfaction. The rate of recurrence appears higher with PPH.
Article Type: Report
Subject: Hemorrhoids (Care and treatment)
Pain, Postoperative (Care and treatment)
Pain (Care and treatment)
Pain (Methods)
Rectum (Prolapse)
Rectum (Care and treatment)
Authors: Madiba, T.E.
Esterhuizen, T.M.
Thomson, S.R.
Pub Date: 01/01/2009
Publication: Name: South African Medical Journal Publisher: South African Medical Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 South African Medical Association ISSN: 0256-9574
Issue: Date: Jan, 2009 Source Volume: 99 Source Issue: 1
Geographic: Geographic Scope: South Africa Geographic Code: 6SOUT South Africa
Accession Number: 204611525
Full Text: First- and second-degree haemorrhoids as well as relatively small third-degree haemorrhoids can be treated non-operatively, and surgery is generally reserved for patients with large third- or fourth-degree haemorrhoids, haemorrhoids with an extensive and symptomatic external component, or patients who have undergone less aggressive therapy with poor results. (1-4) The definitive surgical procedure is excisional haemorrhoidectomy (EH), which can be performed as either an open (Milligan-Morgan) or a closed (Ferguson) operation. (1,5) More recently, Antonio Longo introduced the procedure for prolapse and haemorrhoids (PPH). (6) Both procedures can be undertaken under general or regional anaesthesia (7,8) and are suitable for ambulatory surgery. (7,9-15)

Whereas EH removes the prolapsed haemorrhoids, it does not address the underlying cause of both mucosal and haemorrhoidal prolapse; conversely PPH, by 'lifting' the prolapsed haemorrhoids and mucosa, re-places the haemorrhoidal cushions high in the anal canal, thus reestablishing the topographical relationship between the anal cushions and the rectal muscle layer. (16) Since the staple line is situated in the lower rectal mucosa as opposed to the anal mucosa, and there is no skin incision, it should in theory be associated with less postoperative pain. (6,11) PPH has also been called stapled haemorrhoidectomy, stapled haemorrhoidopexy, stapled anopexy and stapled mucosectomy. This meta-analysis was undertaken to critically compare these two procedures and assess their efficacy in the treatment of haemorrhoids.

Methods

All articles addressing haemorrhoidectomy were identified using the MEDLINE electronic search engine. The keywords used were 'haemorrhoids', 'haemorrhoidectomy', 'stapled haemorrhoidectomy' and 'PPH', with the period of review extending from January 2000 to December 2007. Articles addressing PPH and EH were then reviewed. The search included all languages. All randomised controlled comparative trials and patient samples of [greater than or equal to] 20 patients were considered for the meta-analysis. The primary endpoints assessed were pain, operative time, hospital stay, time taken to return to normal activity, and satisfaction with the operation. The first three were the most robust and the last two less so because of definition variability and fewer studies. Secondary endpoints were bleeding, complications and residual symptoms, recurrence rates and re-interventions. One author (TEM) performed the search and applied the inclusion criteria.

Studies addressing PPH alone were reviewed but not included in the comparison or meta-analysis. The different approaches (open v. closed) and techniques of EH used in the different studies were noted, but no distinction was made between them during the meta-analysis. For the purpose of this meta-analysis 'return to work' and 'return to normal activity' were treated as the same endpoint and 'examination under anaesthesia' performed subsequent to the procedure without an intervention was not regarded as re-intervention. Comparative studies on manometry and cost were also reviewed.

Meta-analysis

All studies using statistically valid outcome comparisons were used and random effects models were applied because of the heterogeneity of the studies. The studies reporting 'mean' and either 'standard deviation' or 'standard error of the mean' (mean [+ or -] SD/SEM) for all or some of the outcomes of interest were evaluated. Outcomes of interest that had been analysed in fewer than two studies and studies that had been analysed non-parametrically and reported medians were not used in the meta-analysis. The software, NCSS (Number Cruncher Statistical Systems, Kaysville, Utah, USA), (17) was used for the meta-analysis and forest plots. All the complications were pooled together and odds ratios were calculated using a random effects model. Where a meta-analysis could not be calculated, the outcomes were qualitatively reviewed. The meta-analysis was performed by one of the authors (TME).

Results

Selection of data sets for analysis

Thirty-seven studies with 2 559 patients were identified comparing the two procedures (Fig. 1). Table I lists the alpha level, power and type II error for the identified studies in peer-reviewed journals. Two studies were excluded because they were not randomised. (18,19) Two studies (20,21) were medium-term follow-ups of patients from two previous randomised controlled trials. (22,23) Their data were only reviewed as follow-up data of the index studies. One further study (24) had a subsequent follow-up study by the same authors. (25)

Inclusion and exclusion criteria were reported in all studies, but were varied. Eleven studies using the mean and standard deviation, and three using the mean and standard error of the mean, were used in one or other aspect of the meta-analysis. The excluded studies included median and range, mean and range or graphs and lack of randomisation. The total number of patients assessed was therefore 2 370 (EH = 1 170 and PPH = 1 200).

Limitations of the studies

The indications for haemorrhoidectomy were inconsistent in that second-, third- and fourth-degree haemorrhoids were included. The parameters and outcome measures were not uniform and were either not clearly defined or defined differently in different studies. 'Time to return to work' and 'time to return to normal activity' were used interchangeably in some studies and differently in others. The morbidity was neither defined nor standardised. The postoperative review was undertaken by an independent observer in only 12 studies. (10,22,24,26-34) Information on recurrence was inconsistent because of variable definitions (recurrent symptoms, prolapse, or haemorrhoids alone or in combination) and their timelines. The patients studied were therefore not homogeneous.

[FIGURE 1 OMITTED]

As there is no bail-out procedure for haemorrhoidectomy it seems that the initial analysis was by 'intention to treat' and, since not all patients returned for follow-up in all studies, it is implicit that follow-up analysis must have been 'per protocol'.

Data analysis

Pain was assessed in all studies and was measured with a 10-point visual analogue score (VAS) in 23 studies (Table II). One study (31) demonstrated a higher pain score for PPH in all categories of pain. Two studies showed similar maximal (30,35) and average (30) pain scores for both procedures. All other studies showed superiority of PPH in terms of less pain for PPH. Operating time was compared in 27 studies and PPH was associated with less operating time in all except three. (30,31,36) Hospital stay was assessed by 20 studies, and it was either similar or less for PPH. Time taken to return to normal activity was shorter for PPH in all 23 studies (Table III). The level of satisfaction was shown to be similar in both procedures (Table IV). The overall recurrence rate was 1% following EH and 4% following PPH, making it four times higher after PPH (Tables IV and V).

When all complications were pooled together (Table V), the average postoperative morbidity for all studies was 48% following EH and 47% following PPH. Incontinence-related problems were similar in both groups (20% v. 24% for EH and PPH respectively). Immediate postoperative bleeding occurred in 2% and 3% in EH and PPH respectively and late bleeding (1 week to 12 months) occurred in 9% and 7% respectively in EH and PPH (Table V).

Re-interventions were necessary in 31 patients following EH (3%) and 42 patients (4%) after PPH. Re-interventions were for bleeding (20 following EH, 21 following PPH), residual haemorrhoids (2 for EH and 8 for PPH), fistula (3 after EH), skin tags (3 after EH and 4 after PPH), fissure (3 after EH), incision of thrombosed external pile (1 after PPH), incision and drainage of a peri-anal abscess (1 after EH), excision of mucosal prolapse (1 for EH and 1 for PPH). When all studies were considered, 11 patients in whom PPH failed underwent EH and 4 underwent unspecified revisional surgery; none of the patients developing recurrence or recurrent symptoms following EH required PPH.

Six studies compared costs but yielded conflicting results. (18,26,30,37-39) The overall cost (including hospital expenses and procedure) for PPH was higher than for EH in 2 studies, (26,30) 1 of which used Ligasure for EH; (26) it was higher for EH in 1 study. (37) The cost per operation was higher for PPH in 2 studies (18,39) and higher for EH in 1 study. (38)

Meta-analysis

The studies used in the meta-analysis addressed return to normal activity (12 studies, 1 178 patients), operative time (11 studies, 1 037 patients), hospital stay (9 studies, 891 patients), pain (8 studies, 815 patients), and satisfaction (4 studies, 387 patients). All effect sizes refer to the comparison of patients undergoing PPH (experimental arm) versus those undergoing EH (control arm). Most of the studies reviewed have been underpowered, and this has necessitated a meta-analysis. A sensitivity analysis was done and showed that the fixed effects analysis was not robust enough. Furthermore the tests for heterogeneity in all the studies used for the meta-analysis showed them to be heterogeneous (p<0.0001). For these reasons the random effects model was used.

The outcome of the meta-analysis is shown graphically by the forest plots of the effect sizes of the various individual studies and the combined effects in Figs 2-6 for each outcome. These figures show that the 95% confidence intervals (CIs) for the combined effect do not overlap with the null value (indicated by the vertical line at zero on the x-axis), except for satisfaction. The patients undergoing PPH therefore experienced a significantly lower mean score for pain, operative time, hospital stay and return to normal activity than did the patients in the control group (EH). The mean score for satisfaction was significantly higher for patients undergoing PPH in 2 studies, (40,41) similar in 1 (28) and higher in those undergoing EH in 1. (30) The overall effect was strongly in favour of PPH. This meta-analysis therefore shows that PPH is superior to EH in terms of postoperative pain, operative time, hospital stay and time to return to normal activity.

Fig. 6 shows pooled results of complications following both procedures. Combined odds ratios (ORs) using random effects model are shown. ORs favour PPH significantly in terms of dehiscence and soiling, they favour EH significantly in terms of prolapse and recurrence, and there were no differences in terms of all the other complications since the 95% CI for the combined effects ORs overlapped with the null value of 1.

Discussion

PPH shows superiority over EH in that it takes less time to perform and is associated with less postoperative pain, a shorter hospital stay and more rapid return to normal activity. Both procedures were followed by a number of complications and residual symptoms, but certain complications tended to occur more after one procedure than the other and vice versa.

The higher stenosis rate following EH was not surprising, as this is a known complication of EH. The presence of more prolapses after PPH was unexpected considering that PPH is designed to limit mucosal prolapse. However, the subjective feeling of a recurrent prolapse is difficult to confirm clinically (42) and, since it may be difficult for patients to distinguish from skin tags, prolapse may be over-estimated. (42,43)

The original PPH stapler (PPH 01, Ethicon Endo-Surgery, Cincinnati, USA) has been modified in an attempt to reduce postoperative bleeding, the main feature being the closed staple height of 0.75 mm compared with 1 mm in the original stapler. (44) Two studies have assessed the PPH 03 stapler and have shown it to be a safe and relatively short procedure with a low rate of postoperative complications such as bleeding. (44,45) It also has the potential to reduce the risk of excision of the internal sphincter and rectal stenosis. Since patients who bleed from the staple line during surgery have an increased chance of postoperative bleeding, such bleeding should be managed by meticulous haemostatic suture placement. (43)

The cause of persistent anal pain after PPH in some patients remains uncertain. (42) Cheetham et al. (46) blamed persistent pain in 5 of 22 patients undergoing PPH on the presence of retained smooth muscle in the doughnut. However, a subsequent study by the same group (47) interestingly failed to demonstrate prolonged pain despite the presence of smooth muscle in the doughnuts. Furthermore 13 of 22 other studies (10,23,27-33,38,39,47,48) showed no association between smooth muscle in doughnuts and persistent pain. It seems therefore that the cause of persistent pain after PPH in a small number of patients remains obscure.

Significant complications specifically associated with PPH have been reported. These include rectal stenosis (10), (49,50) persistent pain (5), (46) rectal perforation (5), (51-53) anal sphincter injury (1), (54) retroperitoneal sepsis (1), (55) rectal obstruction (1), (56) intra-abdominal bleeding (1), (57) rectal bleeding (1), (58) retroperitoneal bleeding (1), (59) and pelvic sepsis (1). (60) Perforation of the rectum following PPH has been blamed on double firing of the stapler (53) or staples cutting through an enterocele. (57) Bleeding may be due to residual staples (58) or seam insufficiency. (59) Admittedly these are isolated case reports and no similar complications are reported relating to EH. Furthermore, when these exceptionally rare complications occur, they can be devastating. With the exception of bleeding, none of these complications was readily found in any of the studies included in the meta-analysis. They may therefore be expected more during the early learning phase of the procedure. Whereas some authors blame the PPH dilator for fragmentation of the internal sphincter, (30) others have failed to demonstrate this effect. (16) We are in agreement with Ravo et al. (61) and Longo (62) that most complications of PPH can be avoided by respecting the rectal wall anatomy in the performance of the procedure.

Although none of the studies had recurrence as a primary endpoint it should be a focus of future studies since, from the data presented here, the rate of recurrence was four times higher following PPH. It is interesting that the number of reinterventions (albeit variable in nature) was similar in both groups. Since none of the studies used repeat PPH to address PPH failure, it seems that failed PPH can only be corrected by EH and EH therefore cannot be completely replaced by PPH. Most of the studies have had short-term follow-up, with only four having >24 months' follow-up. (19-21,41,63) We are in agreement with Brusciano et al. (64) that a failed or complicated PPH is better treated by an experienced colorectal surgeon.

[FIGURE 2 OMITTED]

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[FIGURE 4 OMITTED]

[FIGURE 5 OMITTED]

An increase in the acute-phase reactants results in acute pain and may be responsible for longer hospitalisation and time off work following EH. (65) Furthermore, low-grade inflammation at the site of the staple line causes both anal pain and faecal urgency. (42,66) Early discharge from hospital is favoured by most patients, and it can be reflected in good patient satisfaction and good quality of life. Factors associated with EH such as debilitating pain and poor wound healing may lead to longer hospital stay and later return to normal activity.

[FIGURE 6 OMITTED]

[FIGURE 7 OMITTED]

The earlier return to normal activity after PPH is multifactorial and, although some of the purely operation-dependent factors such as reduced pain, shorter hospital stay and reduced soiling play a role, other social and cultural practices also affect this parameter. (22,67) Cephalad placement of the staple line has also been shown to be associated with quicker return to work. (15)

Despite arbitrary definitions, patient satisfaction was generally good for both procedures. Less pain leads to early return to work, and both outcomes are associated with better quality of life and a happy patient. The shorter operative time for PPH was in terms of minutes and is unlikely to have a bearing on satisfaction. Other factors that lead to dissatisfaction include pain, prolapse, bleeding and persistent soiling. (42)

The use of costly energy devices for haemostasis such as Ligasure and harmonic scalpel in EH equalises the in-hospital procedural costs of the PPH stapler, and is far more expensive than scissors and diathermy. The overall cost of the operation not only includes the cost of operating time, instruments and hospital stay, but also time off work, recurrent medication for symptoms, or recurrence and re-interventions. Hence overall cost, which has not been very well addressed in the literature, should be the benchmark for future financial comparisons.

Four other systemic reviews and meta-analyses (8,68-70) have been published in the past 6 years. The first, by Sutherland et al., (70) reviewed 7 randomised controlled studies of which 6 were used in that meta-analysis. They used a fixed effects model rather than a random effects model. They included 4 of the 13 studies used for our random effects model analysis, which contains 9 studies conducted since their analysis. They stated that there was a 'reasonably clear evidence in favour of PPH in terms of reduced bleeding at two weeks and reduced length of hospital stay'.

Nisar et al. (8) in 2004 reviewed 15 randomised controlled trials with 1 077 patients and undertook a meta-analysis on the pooled data. They noted PPH to be associated with less pain as well as shorter hospital stay, reduced operative time and more rapid return to normal activity. PPH, however, had a higher recurrence rate at minimum follow-up of 6 months. They concluded that EH was still a gold standard. Another systematic review of 10 randomised trials was published by Lan et al. in 2006. (68) They only used studies in which the EH was performed by the Milligan-Morgan technique and they utilised only 3 of the studies employed in our random effects model analysis. They noted clear evidence in favour of PPH for reduced operative time, length of hospital stay, pain, anal discharge and increased satisfaction. PPH was no more superior to EH with regard to postoperative bleeding, resumption of normal activity, incontinence, anal resting and squeeze pressures. The most recent meta-analysis was published by Shao et al. in 2008. (69) They analysed safety of the procedure and noted that there was insufficient evidence to advocate performing PPH in a day-case setting; they further concluded that PPH was at least as safe as EH and that it can be supported by a reasonable conventional operation for third- and fourth-degree haemorrhoids.

The former 3 systematic reviews used fewer studies than the present meta-analysis, and that by Shao et al. (69) was more comprehensive. The present systematic review has included 33 studies, has undertaken meta-analysis in 13 studies, and has made use of forest plots to tabulate the trends graphically, thus making the data more robust than the data in the other 4 analyses. We have also assessed statistical power and likelihood of type II error of the studies, although this was not used to exclude the studies. There are several facets of this meta-analysis which provide better definition of the way forward in future studies, including the use of only third-degree haemorrhoids; recurrent bleeding, recurrent haemorrhoids and complications all need to be clearly defined endpoints. In long-term studies better data on overall costs are required, as PPH may lead to increased procedural cost. Furthermore, overall cost should take cognisance of the time taken to return to normal activity.

All the meta-analyses including the present meta-analysis are in agreement that there was significant heterogeneity between the results of trials available for the meta-analysis caused by relatively small sample sizes, variation in severity of disease, type of haemorrhoidectomy performed and method of reporting outcomes, and that trial results are difficult to interpret owing to variation in patient selection and methods of reporting endpoints, short follow-up times and poor reporting of complications. This significant heterogeneity is still evident in the studies we have added in this review and continues to detract from the robustness of the analysis. The possibility of publication bias cannot be excluded. The data available on long-term outcomes are also limited. More rigorous studies are needed with longer-term follow-up and larger sample sizes.

The appraisal committee of the recently published NICE technology appraisal on PPH4 also reached the same conclusions as the present meta-analysis. Other more recently published studies continue to show this trend, even in thrombosed haemorrhoids. (71)

Summary

Short-term results demonstrate superiority of PPH over EH in terms of pain, earlier return to normal activity and a minor reduction in operative time. This must be tempered by what appears to be a higher risk of recurrence which may or may not require further surgery. This long-term recurrence risk has never been a primary endpoint and, until more long-term data from better stratified series are reported, PPH cannot usurp EH as the best long-term cure for haemorrhoids. There are compelling reasons for EH which cannot be met by PPH, including acutely incarcerated and thrombosed haemorrhoids, presence of gangrene, the need for limited haemorrhoidectomy and the presence of numerous skin tags. (2,71)

Since both operations are associated with satisfactory results and since failure of PPH can be managed by EH, it is advisable that all surgeons learn both techniques. Surgeons should be aware that PPH may result in damage to the internal anal sphincter and other complications which, although exceptionally rare, may be life-threatening, and that EH is associated with its own set of more common but highly disturbing problems such as postoperative pain and anal stenosis. A surgeon competent to perform either PPH or EH should decide on the specific technique only after adequate discussion with his patient, including a detailed explanation of alternatives, benefits and procedure-related complications.

Accepted 23 October 2008.

References

(1.) Madoff RD, Fleshman JW. American Gastroenterological Association technical review on the diagnosis and treatment of hemorrhoids. Gastroenterology 2004; 126: 1463-1473.

(2.) Sardinha TC, Corman ML. Hemorrhoids. Surg Clin North Am 2002; 82: 1153-1167.

(3.) Senagore AJ. Surgical management of hemorrhoids. J Gastrointest Surg 2002; 6: 295-297.

(4.) Tucker H, George E, Barnett D, et al. NICE technology appraisal on stapled haemorrhoidopexy for the treatment of haemorrhoids. Ann R Coll Surg Engl 2008; 90: 82-84.

(5.) McRae HM, McLeod RS. Comparison of hemorrhoidal treatment modalities. A meta-analysis. Dis Colon Rectum 1995; 38: 687-694.

(6.) Longo A. Treatment of haemorrhoidal disease by reduction of mucosa and haemorrhoidal prolapse with a circular suturing device: a new procedure. Proceedings of the 6th World Congress of Endoscopic Surgery, Rome, 3-6 June 1998, 777-784.

(7.) Esser S, Khubchandani I, Rakhmanine M. Stapled hemorrhoidectomy with local anesthesia can be performed safely and cost-efficiently. Dis Colon Rectum 2004; 47: 1164-1169.

(8.) Nisar PJ, Acheson AG, Neal KR, et al. Stapled hemorrhoidopexy compared with conventional hemorrhoidectomy: systemic review of randomized, controlled trials. Dis Colon Rectum 2004; 47: 1837-1845.

(9.) Hunt L, Luck AJ, Rudkin G, et al. Day-case haemorrhoidectomy. Br J Surg 1999; 86: 255-258.

(10.) Kairaluoma M, Nuorva K, Kellokumpu I. Day-case stapled (circular) vs diathermy hemorrhoidectomy. Dis Colon Rectum 2003; 46: 93-99.

(11.) Singer MA, Clintron JR, Fleshman J, et al. Early experience with stapled hemorrhoidectomy in the United States. Dis Colon Rectum 2002; 45: 360-367.

(12.) Guy RJ, Seow-Choen F. Septic complications after treatment of haemorrhoids. Br J Surg 2003; 90: 147-156.

(13.) Thompson-Fawcett MW, Cook TA, Baigrie RJ, et al. What patients think of day surgery proctology. Br J Surg 1998; 85: 1388.

(14.) Beattie GC, MacAdam TK, McIntosh SA, et al. Day case stapled haemorrhoidopexy for prolapsing haemorrhoids. Colorect Dis 2006; 8: 56-61.

(15.) Plocek MD, Kondylis LA, Duhan-Floyd N, et al. Hemorrhoidopexy staple line height predicts return to work. Dis Colon Rectum 2006; 49: 1905-1909.

(16.) Altomare DF, Rinaldi M, Sallustio PL, et al. Long-term effects of stapled haemorrhoidectomy on internal anal function and sensitivity. Br J Surg 2001; 88: 1487-1491.

(17.) Hintze J. NCSS and PASS. Number Cruncher Statistical Systems. www ncss com 2001 (accessed 29 October 2008).

(18.) Goulimaris I, Kanellos I, Christoforidis E, et al. Stapled haemorrhoidectomy compared with Milligan-Morgan excision for the treatment of prolapsing haemorrhoids: a prospective study. Eur J Surg 2002; 168: 621-625.

(19.) Mattana C, Coco C, Manno A, et al. Stapled hemorrhoidopexy and Milligan Morgan hemorrhoidectomy in the cure of fourth-degree hemorrhoids: Long term evaluation and clinical results. Dis Colon Rectum 2007; 50: 1770-1775.

(20.) Au-Yong I, Rowsell M, Hemingway DM. Randomised controlled clinical trial of stapled haemorrhoidectomy vs conventional haemorrhoidectomy: a three and half year follow-up. Colorect Dis 2004; 6: 37-38.

(21.) Smyth EF, Baker RP, Wilken BJ, et al. Stapled versus excision haemorrhoidectomy: long term follow-up of a randomised controlled trial. Lancet 2003; 361: 1437.

(22.) Mehigan BJ, Monson JRT, Hartley JE. Stapling procedure for haemorrhoids versus Milligan-Morgan haemorrhoidectomy: randomised controlled trial. Lancet 2000; 355: 782-785.

(23.) Rowsell M, Bello M, Hemingway DM. Circumferential mucosectomy (stapled haemorrhoidectomy) versus conventional haemorrhoidectomy: randomised controlled trial. Lancet 2000; 355: 779-781.

(24.) Ganio E, Altomare DF, Gabrielli F, et al. Prospective randomised multicentre trial comparing stapled with open haemorrhoidectomy. Br J Surg 2001; 88: 669-674.

(25.) Ganio E, Altomare DF, Milito G, et al. Long-term outcome of a multicentre randomised clinical trial of stapled haemorrhoidectomy versus Milligan-Morgan haemorrhoidectomy. Br J Surg 2007; 94: 1033-1037.

(26.) Basdanis G, Papadopoulos VN, Michalopoulos A, et al. Randomized clinical trial of stapled hemorrhoidectomy vs open with Ligasure for prolapsed piles. Surg Endosc 2005; 19: 235-239.

(27.) Chung CC. Stapled hemorrhoidectomy vs harmonic scalpel hemorrhoidectomy: A randomized trial. Dis Colon Rectum 2005; 48: 1215-1219.

(28.) Correa-Rovelo JM, Tellez O, Obregon L, et al. Stapled rectal mucosectomy vs closed hemorrhoidectomy. A randomised, clinical trial. Dis Colon Rectum 2002; 45:1367-1375.

(29.) Hetzer FH, Demartines N, Handschin AE, et al. Stapled vs excision hemorrhoidectomy. Long term results of prospective randomized trial. Arch Surg 2002; 137: 337-340.

(30.) Ho Y-H, Cheong W-K, Tsang C, et al. Stapled hemorrhoidectomy--cost and effectiveness. Randomised controlled trial including incontinence scoring, anorectal manometry and endoanal ultrasound assessments at up to three months. Dis Colon Rectum 2000; 43: 1666-1675.

(31.) Lau PYY, Meng WCS, Yip AWC. Stapled haemorrhoidectomy in Chinese patients: A prospective randomised control study. Hong Kong Med J 2004; 10: 373-377.

(32.) Ortiz H, Marzo J, Armendariz P. Randomised clinical trial of stapled haemorrhoidopexy versus conventional diathermy haemorrhoidectomy. Br J Surg 2002; 89: 1376-1381.

(33.) Ortiz H, Marzo J, Armendariz P, et al. Stapled hemorrhoidectomy vs diathermy excision for fourth degree hemorhoids: a randomised clinical trial and review of the literature. Dis Colon Rectum 2005; 48: 809-815.

(34.) Pavlidis T, Papaziogas B, Souparis A, et al. Modern stapled Longo procedure vs conventional Milligan-Morgan hemorrhoidectomy: a randomised controlled trial. Int J Colorect Dis 2002; 17: 50-53.

(35.) Palimento D, Picchio M, Attanasio U, et al. Stapled and open hemorrhoidectomy: randomized controlled trial of early results. World J Surg 2003; 27: 203-207.

(36.) Brown SR, Ballan K, Ho E, et al. Stapled mucosectomy for acute thrombosed circumferentially prolapsed piles: a prospective randomised comparison with conventional haemorrhoidectomy. Colorect Dis 2001; 3: 175-178.

(37.) Boccasanta P, Capretti PG, Venturi M, et al. Randomized controlled trial between stapled circumferential mucosectomy and conventional circular hemorrhoidectomy in advanced hemorrhoids with external mucosa prolapse. Am J Surg 2001; 182: 64-68.

(38.) Hasse C, Sitter H, Brune M, et al. Hamorrhoidektomie: Konventionelle exzision versus resektion mit dem klammernahtgerat. Prospektiv, randomisierte studie. Dtsch Med Wochenschr 2004; 129: 1611-1617.

(39.) Wilson MS, Pope V, Doran HE, et al. Objective comparison of stapled anopexy and open haemorhoidectomy. A randomized controlled trial. Dis Colon Rectum 2002; 45: 1437-1444.

(40.) Bikhchandani J, Agarwal PN, Kant R, et al. Randomized controlled trial to compare the early and mid-term results of stapled versus open hemorrhoidectomy. Am J Surg 2005; 189: 56-60.

(41.) Racalbuto A, Aliiotta I, Corsaro G, et al. Hemorrhoidal stapler prolapsectomy vs Milligan-Morgan hemorrhoidectomy: a long term randomized trial. Int J Colorect Dis 2004; 19: 239-244.

(42.) Fueglistaler P, Guenin MO, Montali I, et al. Long-term results after hemorrhoidopexy: High patient satisfaction despite frequent postoperative symptoms. Dis Colon Rectum 2007; 50: 204-212.

(43.) Koh DC, Cheong DM, Wong KS. Stapled haemorrhoidectomy: bothersome staple line bleeding. Asian J Surg 2005; 28: 193-197.

(44.) Lim YK, Eu K-W, Ho KS, et al. PPH03 stapled hemorrhoidectomy: our experience. Tech Coloproctol 2006; 10: 43-46.

(45.) Angelone G, Giardiello C, Prota C. Bleeding after stapled haemorrhoidopexy using the PPH 03 stapler device. Chir Ital 2007; 59: 225-229.

(46.) Cheetham MJ, Mortensen NJM, Nystrom P-O, et al. Persistent pain and faecal urgency after stapled haemorrhoidectomy. Lancet 2000; 356: 730-733.

(47.) Cheetham MJ, Cohen CRG, Kamm MA, et al. A randomized, controlled trial of diathermy hemorrhoidectomy vs stapled hemorrhoidectomy in an intended day-care setting with longer follow-up. Dis Colon Rectum 2003; 46: 491-497.

(48.) Khalil KH, O'Bichere A, Sellu D. Randomised clinical trial of sutured versus stapled closed haemorrhoidectomy. Br J Surg 2000; 87:1352-1355.

(49.) Yao L, Zhong Y, Xu J, et al. Rectal stenosis after procedures for prolapse and hemorrhoids (PPH)--a report from China. World J Surg 2006; 30: 1311-1315.

(50.) Peterson S, Hellmich G, Schulmann D, et al. Early rectal stenosis following stapled rectal mucosectomy for hemorrhoids. BMC Surg 2004; 4: 6.

(51.) Herold A, Kirsch J, Staude G, et al. A German multicentre study on circular stapled haemorrhoidectomy. Colorect Dis 2000; 2(suppl):

18.

(52.) Wong LY, Jiang JK, Cang SC, et al. Rectal perforation: a life-threatening complication of stapled hemorrhoidectomy: report of a case. Dis Colon Rectum 2003; 46: 116-117.

(53.) Ripetti V, Caricato M, Arullani A. Rectal perforation, retropneumoperitoneum and pneumomediastinum after stapling procedure for prolapsed hemorrhoids: report of a case and subsequent considerations. Dis Colon Rectum 2002; 45: 268-270.

(54.) Ho Y-H, Seow-Choen F, Tsang C, et al. Randomised trial assessing anal sphincter injuries after stapled haemorrhoidectomy. Br J Surg 2001; 88: 1449-1455.

(55.) Maw A, Eu K-W, Seow-Choen F. Retroperitoneal sepsis complicating stapled hemorrhoidectomy: report of a case and review of the literature. Dis Colon Rectum 2002; 45: 826-828.

(56.) Cipriani S, Pescatori M. Acute rectal obstruction after PPH stapled haemorrhoidectomy. Colorect Dis 2002; 4: 367-370.

(57.) Aumann G, Petersen S, Pollack T. Severe intra-abdominal bleeding following stapled mucosectomy due to enterocoele: report of a case. Tech Coloproctol 2004; 8: 41-43.

(58.) Quah HM, Hadi HIA, Hay DJ, et al. Residual staples as a possible cause of recurrent rectal bleeding after stapled haemorrhoidectomy. Colorect Dis 2003; 6: 196.

(59.) Meyer P, Stieger R. Retroperitoneales hamatom mit sekundarer nahtinsuffizienz komplikation einer staplermukosektomie hemorrhoidectomy. Chirurg 2004; 75: 1125-1127.

(60.) Molloy RG, Kingsmore D. Life threatening pelvic sepsis after stapled haemorrhoidectomy. Lancet 2000; 355: 810.

(61.) Ravo B, Amato A, Bianco V, et al. Complications after stapled haemorrhoidectomy: Can they be prevented? Tech Coloproctol 2002; 6: 83-88.

(62.) Longo A. PPH at 10 years. Paper presented at the Cleveland Clinic Florida 18th Annual International Colorectal Disease Symposium, 15-17 February 2007, Fort Lauderdale, Florida.

(63.) Van de Stadt J, D'Hoore A, Duinslaeger M, et al. Long-term results after excision haemorrhoidectomy versus stapled haemorrhoidectomy for prolapsing haemorrhoids. A Belgian prospective randomized trial. Acta Chir Belg 2005; 105: 44-52.

(64.) Brusciano L, Ayabaca SM, Pescatori M, et al. Re-interventions after complicated or failed stapled hemorrhoidectomy. Dis Colon Rectum 2004; 47: 1846-1851.

(65.) Krska Z, Kvasnieka J, Faltyn J, et al. Surgical treatment of haemorrhoids according to Longo and Milligan Morgan: an evaluation of postoperative tissue response. Colorect Dis 2003; 5: 573-576.

(66.) Thaha MA, Irvine LA, Steele RJ, et al. Post-defaecation pain syndrome after circular stapled anopexy is abolished by oral nifedipine. Br J Surg 2005; 92: 208-210.

(67.) Senagore AJ, Singer MA, Abcarian H, et al. A prospective randomized, controlled multicenter trial comparing stapled hemorrhoidopexy and Ferguson hemorrhoidectomy: peri-operative and one-year results. Dis Colon Rectum 2004; 47: 1824-1836.

(68.) Lan P, Wu X, Zhou X, et al. The safety and efficacy of stapled hemorrhoidectomy in the treatment of hemorrhoids: a systematic review and meta-analysis of ten randomised control trials. Int J Colorect Dis 2006; 21: 172-177.

(69.) Shao W-J, Li G-CH, Zhang ZH-K, et al. Systematic review and meta-analysis of randomised controlled trials comparing stapled haemorrhoidopexy with conventional haemorrhoidectomy. Br J Surg 2008; 95: 147-160.

(70.) Sutherland LM, Matsuda BK, Sweeny JL, et al. A systematic review of stapled hemorrhoidectomy. Arch Surg 2002; 137: 1395-1406.

(71.) Wong JCH, Chung CC, Yau KK, et al. Stapled technique for acute thromobosed hemorrhoids: a randomised controlled trial with long term results. Dis Colon Rectum 2008; 51: 397-403.

(72.) Helmy MA. Stapling procedure for haemorrhoids versus conventional haemorrhoidectomy. J Egypt Soc Parasitol 2000; 30: 951-958.

(73.) Shalaby R, Desoky A. Randomised clinical trial of stapled versus Milligan-Morgan haemorrhoidectomy. Br J Surg 2001; 88: 1049-1053.

(74.) Gravie JF, Lehur P-A, Huten N, et al. Stapled hemorrhoidopexy versus Milligan-Morgan hemorrhoidectomy. A prospective randomized multicenter trial with 2-year postoperative follow-up. Ann Surg 2005; 242: 29-35.

(75.) Kraemer M, Parulava T, Roblick M, et al. Prospective randomised study: Proximate PPH vs Ligasure for haemorrhoidal surgery. Dis Colon Rectum 2005; 48: 1517-1522.

(76.) Sabanci U, Ogun I, Candemir G. Stapled haemorrhoidopexy versus Ferguson haemorrhoidectomy: a prospective study with 2-year postoperative follow-up. J Int Med Res 2007; 35: 917-921.

(77.) Ascanelli S, Gregorio C, Tonini G, et al. Long stapled haemorrhoidectomy versus Milligan-Morgan procedure: short and long term results of a randomised, controlled prospective trial. Chir Ital 2005; 57: 439-447.

Department of Surgery, University of KwaZulu-Natal, Durban, and Colorectal Unit, Inkosi Albert Luthuli Central

Hospital, Durban

T E Madiba, MB ChB, MMed, PhD, FCS (SA), FASCRS

College of Health Sciences, University of KwaZulu-Natal, Durban

T M Esterhuizen, MSc (Epidemiol)

Department of Surgery, University of KwaZulu-Natal, Durban

S R Thomson, MB ChB, ChM, FRCS (Edin)

Corresponding author: T E Madiba (madiba@ukzn.ac.za)
Table I. Analysis of different studies identified

                                   No. per   Indication       EH
Author                      Year    group    (degree)         method

Helmy (72)                  2000     20      2nd & 3rd        Diathermy
Ho et al. (30)              2000   62 & 57   4th              Diathermy
Khalil et al. (48)          2000     20      3rd              Diathermy
Mehigan et al. (22)         2000     20      2nd & 3rd        Diathermy
Rowsell et al. (23)         2000     11      3rd              Diathermy
Boccasanta et al. (37)      2001     40      4th              Scissors
Brown et al. (36)           2001     15      4th              Diathermy
Ganio et al. (24)           2001     50      3rd & 4th        Diathermy
Shalaby & Desoky (73)       2001     100     2nd & 3rd        Scissors
Correa-Rovelo et al. (28)   2002     42      3rd & 4th        Diathermy
Hetzer et al. (29)          2002     20      2nd & 3rd        Scissors
Ortiz et al. (32)           2002   27 & 28   3rd & 4th        Diathermy
Pavlidis et al. (34)        2002     20      2nd, 3rd & 4th   Scissors
Wilson et al. (39)          2002   30 & 27   3rd              Diathermy
Au-Yong et al. (20)         2003   11 & 9    3rd              Diathermy
Cheetham et al. (47)        2003   16 & 15   2nd & 3rd        Diathermy
Kairaluoma et al. (10)      2003     30      3rd              Diathermy
Krska et al. (65)           2003     25      3rd              Scissors
Palimento et al. (35)       2003     37      3rd & 4th        Diathermy
Racalbuto et al. (41)       2003     50      3rd & 4th        Scissors
Smyth et al. (21)           2003   20 & 16   2nd & 3rd        Diathermy
Basdanis et al. (26)        2004   50 & 45   3rd & 4th        Ligasure
Hasse et al. (38)           2004     40      3rd              Diathermy
Lau et al. (31)             2004     12      2nd & 3rd        Diathermy
Senagore et al. (67)        2004   59 & 58   3rd              Scissors
Bikhchandani et al. (40)    2005     42      3rd & 4th        Scissors
Chung et al. (27)           2005   45 & 43   3rd & 4th        Harmonic
Gravie et al. (74)          2005     63      Symptomatic      Scissors
Kraemer et al. (75)         2005     25      3rd & 4th        Ligasure
Ortiz et al. (33)           2005   15 & 16   ? 3rd & 4th      Diathermy
Van de Stadt et al. (63)    2005     20      2nd & 3rd        Scissors
Sabanci et al. (76)         2007     50      3rd & 4th        Diathermy
Ascanelli et al. (77)       2005     50      2nd & 3rd        Scissors
Goulimaris et al. (18)      2002   48 & 37   3rd & 4th        Diathermy
Mattana et al. (19)         2007     50      4th              Scissors

                            Alpha
Author                      level   Power   Type II error

Helmy (72)                   NS      NS     Unknown
Ho et al. (30)               5%      NS     Not likely
Khalil et al. (48)           5%      80%    Possible
Mehigan et al. (22)          5%      80%    Not likely
Rowsell et al. (23)          5%      80%    Possible
Boccasanta et al. (37)       5%      NS     Not likely
Brown et al. (36)            5%      NS     Possible
Ganio et al. (24)            5%      20%    Not likely
Shalaby & Desoky (73)        5%      NS     Not likely
Correa-Rovelo et al. (28)    5%      NS     Not likely
Hetzer et al. (29)           5%      NS     Not likely
Ortiz et al. (32)            5%      80%    Not likely
Pavlidis et al. (34)         5%      NS     Not likely
Wilson et al. (39)           5%      NS     Not likely
Au-Yong et al. (20)          NS      NS     Very possible
Cheetham et al. (47)         5%      80%    Possible
Kairaluoma et al. (10)       5%      80%    Possible
Krska et al. (65)            5%      NS     Possible
Palimento et al. (35)        5%      90%    Not likely
Racalbuto et al. (41)        NS      NS     Not likely
Smyth et al. (21)            NS      NS     Possible
Basdanis et al. (26)         5%      NS     Not likely
Hasse et al. (38)            5%      NS     Not likely
Lau et al. (31)              5%      80%    Possible
Senagore et al. (67)         5%      95%    Not likely
Bikhchandani et al. (40)     5%      NS     Not likely
Chung et al. (27)            5%      80%    Not likely
Gravie et al. (74)           5%      NS     Not likely
Kraemer et al. (75)          NS      NS     Possible
Ortiz et al. (33)            5%      NS     Not likely
Van de Stadt et al. (63)     5%      NS     Possible
Sabanci et al. (76)          5%      NS     Possible
Ascanelli et al. (77)        5%      NS     Possible
Goulimaris et al. (18)       5%      NS     Possible
Mattana et al. (19)          5%      NS     Possible

NS = not stated.

Table II. Comparison of studies comparing pain between EH and PPH

                                                 Maximal pain

Author                      Year    No.        EH           PPH

Basdanis et al. (26)        2004      95    6 (3-7)       3 (1-6)
Bikhchandani et al. (40)    2005      84   6.4 (1.4)     1.1 (1.2)
Brown et al. (36)           2001      30    1 (0-10)     5 (2-10)
Cheetham et al. (47)        2003      31    9 (2-10)     5 (1-10)
Chung et al. (27)           2005      88       --           --
Correa-Rovelo et al. (28)   2002      84   7.2 (1.7)     4.6 (2.1)
Ganio et al. (24)           2001     100       --           --
Gravie et al. (74)          2005     126       --           --
Helmy (72)                  2000      40   6.5 (3-9)    2.1 (0.2-8)
Hetzer et al. (29)          2002      40       --           --
Ho et al. (30)              2000     119    5 (0.4)      4.8 (0.4)
Kairaluoma et al. (10)      2003      60   4.3 (1-6)    1.8 (0.1-5)
Krska et al. (65)           2003      50      3.7           2.4
Lau et al. (31)             2004      24   4.7 (3.4)     5.4 (3.4)
Mehigan et al. (22)         2000      40       --           --
Ortiz et al. (32)           2002      55       --           --
Ortiz et al. (33)           2005      31       --           --
Palimento et al. (35)       2003      74    3 (3-7)       3 (1-6)
Pavlidis et al. (34)        2002      80   2.4 (0.5)     0.7 (0.2)
Rowsell et al. (23)         2000      22       -             -
Sabanci et al. (76)         2007     100    7.4 (1)      4.2 (0.8)
Senagore et al. (67)        2004     156       --           --
Shalaby & Desoky (73)       2001   2 000       --           --

                                  Average pain

Author                          EH            PPH

Basdanis et al. (26)            --            --
Bikhchandani et al. (40)        --            --
Brown et al. (36)               --            --
Cheetham et al. (47)            --            --
Chung et al. (27)             4 (2-6)       2 (1-6)
Correa-Rovelo et al. (28)    5.5 (1.4)     2.8 (1.4)
Ganio et al. (24)               --            --
Gravie et al. (74)           4.2 (2.2)     2.7 (2.2)
Helmy (72)                      --            --
Hetzer et al. (29)          5.7 (1-10)     1.4 (0-8)
Ho et al. (30)                3 (0.7)       3 (0.6)
Kairaluoma et al. (10)          --            --
Krska et al. (65)               --            --
Lau et al. (31)               3.1 (2)       4 (3.8)
Mehigan et al. (22)          6.5 (3-9)    2.1 (0.2-8)
Ortiz et al. (32)            3.5 (1-6)     1.2 (0-2)
Ortiz et al. (33)           2.8 (0.9-6)   0.9 (0.4-2)
Palimento et al. (35)           --            --
Pavlidis et al. (34)            --            --
Rowsell et al. (23)          4.4 (0.5)     2.1 (0.5)
Sabanci et al. (76)             --            --
Senagore et al. (67)            --            --
Shalaby & Desoky (73)        7.6 (0.7)     2.5 (1.3)

                                   Pain on
                                 defaecation

Author                         EH           PPH

Basdanis et al. (26)           --           --
Bikhchandani et al. (40)       --           --
Brown et al. (36)              --           --
Cheetham et al. (47)           --           --
Chung et al. (27)              --           --
Correa-Rovelo et al. (28)      --           --
Ganio et al. (24)              --           --
Gravie et al. (74)             --           --
Helmy (72)                     --           --
Hetzer et al. (29)             --           --
Ho et al. (30)                 --           --
Kairaluoma et al. (10)         --           --
Krska et al. (65)              --           --
Lau et al. (31)             3.7 (5.2)    5.4 (3.4)
Mehigan et al. (22)            --           --
Ortiz et al. (32)              --           --
Ortiz et al. (33)              --           --
Palimento et al. (35)        7 (3-9)      5 (3-7)
Pavlidis et al. (34)           --           --
Rowsell et al. (23)            --           --
Sabanci et al. (76)            --           --
Senagore et al. (67)           6.6          4.9
Shalaby & Desoky (73)          --           --

Figures in parentheses are standard deviation or range.

Table III. Studies comparing different
short-term outcomes between EH and PPH

                                               Op. time (min)

Author                      Year   No.        EH            PPH

Ho et al. (30)              2000    119   11.4 (0.9)    17.6 (1.3)
Rowsell et al. (23)         2000     22   14.8 (1)      14.1 (2)
Boccasanta et al. (37)      2001     80   15 (5-25)     15 (10-40)
Shalaby & Desoky (73)       2001    200   19.7 (4.7)    9 (3)
Correa-Rovelo et al. (28)   2002     84   46 (10)       12 (3)
Pavlidis et al. (34)        2002     80   35 (10)       23 (5)
Basdanis et al. (26)        2005     95   NS            NS
Hasse et al. (38)           2004     80   49 (12)       16 (0.8)
Racalbuto et al. (41)       2004    100   22.8 (2)      19.4 (5)
Bikhchandani et al. (40)    2005     84   45 (5)        24 (4)
Chung et al. (27)           2005     88   18.5 (6)      17 (7)
Gravie et al. (74)          2005    126   31            21
Helmy (72)                  2000     40   22 (15-25)    18 (9-25)
Khalil et al. (48)          2000     40   40 (15-65)    21 (14-60)
Mehigan et al. (22)         2000     40   22 (15-25)    18 (9-25)
Brown et al. (36)           2001     35   15 (5-25)     15 (10-40)
Ganio et al. (24)           2001    100   NS            NS
Hetzer et al. (29)          2002     20   43 (25-60)    30 (15-45)
Ortiz et al. (32)           2002     55   33.5 (15-90)  19 (14-35)
Cheetham et al. (47)        2003     31   NS            NS
Palimento et al. (35)       2003     52   30 (20-40)    25 (15-49)
Kairaluoma et al. (10)      2003     60   22 (14-40)    21 (11-59)
Krska et al. (65)           2003     50   46            28
Wilson et al. (39)          2002     99   18 (13-21)    12 (10-15)
Senagore et al. (67)        2004    156   30 (12-89)    26 (5-79)
Kraemer et al. (75)         2005     50   18 (10-37)    15 (6-0)
Lau et al. (31)             2004     24   30            35
Ortiz et al. (33)           2005     31   39            24
Van de Stadt et al. (63)    2005     40   25.7          22.2
Sabanci et al. (76)         2007    100   36.3 (3.5)    15.3 (4)
Ascanelli et al. (77)       2005    100   NS            NS

                                Hospital stay (d)

Author                          EH            PPH

Ho et al. (30)              2 (0.1)       2 (0.1)
Rowsell et al. (23)         2.8 (0.1)     1.1 (0.3)
Boccasanta et al. (37)      3 (0.4)       2 (0.5)
Shalaby & Desoky (73)       2.2 (0.5)     1.1 (0.2)
Correa-Rovelo et al. (28)   NS            NS
Pavlidis et al. (34)        3.2 (0.3)     1.7 (0.5)
Basdanis et al. (26)        2.1 (2-3)     1.6 (1-2)
Hasse et al. (38)           4 (0.8)       1 (0.5)
Racalbuto et al. (41)       2.3 (2.4)     2.1 (0.3)
Bikhchandani et al. (40)    2.8 (2-5)     1.2 (1-5)
Chung et al. (27)           3 (2-5)       1 (1-5)
Gravie et al. (74)          3.1 (1.7)     2.2 (1.2)
Helmy (72)                  1 (0-3)       1 (0-4)
Khalil et al. (48)          NS            NS
Mehigan et al. (22)         1 (0-3)       1 (0-4)
Brown et al. (36)           2 (2-4)       2 (1-5)
Ganio et al. (24)           2 (0-12)      1 (0-3)
Hetzer et al. (29)          2.1 (1-4)     2.4 (1-4)
Ortiz et al. (32)           NS            NS
Cheetham et al. (47)        NS            NS
Palimento et al. (35)       NS            NS
Kairaluoma et al. (10)      NS            NS
Krska et al. (65)           6.2           3.5
Wilson et al. (39)          2 (1-2)       1 (0.8-2)
Senagore et al. (67)        NS            NS
Kraemer et al. (75)         NS            NS
Lau et al. (31)             2.25          1.5
Ortiz et al. (33)           NS            NS
Van de Stadt et al. (63)    2.25          1.5
Sabanci et al. (76)         NS            NS
Ascanelli et al. (77)       2 (0.3-2)     1 (0.3-1.6)

                                 N. activity (d)

Author                          EH            PPH

Ho et al. (30)              23 (2)        17 (2)
Rowsell et al. (23)         17 (2.3)      8 (1.5)
Boccasanta et al. (37)      15 (1.4)      8 (0.9)
Shalaby & Desoky (73)       53.9 (5.8)    8.2 (0.9)
Correa-Rovelo et al. (28)   15 (5)        6 (4)
Pavlidis et al. (34)        NS            NS
Basdanis et al. (26)        9.8 (2)       6.3 (2)
Hasse et al. (38)           21 (7)        11 (7)
Racalbuto et al. (41)       16.9 (2.5)    8.0 (1.4)
Bikhchandani et al. (40)    17.6 (5.6)    8.1 (2.5)
Chung et al. (27)           15.6 (6)      6.7 (4.3)
Gravie et al. (74)          24 (13)       14 (10)
Helmy (72)                  34 (14-90)    17 (3-60)
Khalil et al. (48)          NS            NS
Mehigan et al. (22)         34 (14-90)    17 (3-60)
Brown et al. (36)           28 (14-81)    14 (5-34)
Ganio et al. (24)           13 (3-25)     5 (1-16)
Hetzer et al. (29)          20.7 (7-45)   6.7 (2-14)
Ortiz et al. (32)           3.8 (0-16)    3.3 (0-14)
Cheetham et al. (47)        14 (3-21)     10 (3-38)
Palimento et al. (35)       34 (16-50)    28 (12-40)
Kairaluoma et al. (10)      14 (1-33)     8 (1-21)
Krska et al. (65)           25.3          12
Wilson et al. (39)          --            --
Senagore et al. (67)        NS            NS
Kraemer et al. (75)         NS            NS
Lau et al. (31)             NS            NS
Ortiz et al. (33)           NS            NS
Van de Stadt et al. (63)    NS            NS
Sabanci et al. (76)         28.3 (2.9)    10 (1.8)
Ascanelli et al. (77)       NS            NS

Figures in parentheses are standard deviation or range.
NS = not stated.
N. activity = time taken to return to normal activity.

Table IV. Studies comparing different medium-term outcomes
between PPH and EH

                                         Satisfaction *

Author                      Year   No.   EH        PPH

Ho et al. (30)              2000   119   8.6       8.2
Rowsell et al. (23)         2000    22   NS        NS
Boccasanta et al. (37)      2001    80   NS        NS
Shalaby & Desoky (73)       2001   200   80%       92%
Correa-Rovelo et al. (28)   2002    84   9         9.2
Pavlidis et al. (34)        2002    80   89%       95%
Basdanis et al. (26)        2005    95   NS        NS
Hasse et al. (38)           2004    80   73%       71%
Racalbuto et al. (41)       2004   100   NS        NS
Bikhchandani et al. (40)    2005    84   6.0       6.9
Chung et al. (27)           2005    88   2         3
Gravie et al. (74)          2005   126   Similar   Similar
Goulimaris et al. (18)      2002    85   Similar   Similar
Helmy (72)                  2000    40   75%       85%
Khalil et al. (48)          2000    40   2         1
Mehigan et al. (22)         2000    40   85%       75%
Brown et al. (36)           2001    35   NS        NS
Ganio et al. (24)           2001   100   Similar   Similar
Hetzer et al. (29)          2002    20   NS        NS
Ortiz et al. (32)           2002    55   9.3       7.6
Cheetham et al. (47)        2003    31   2         2
Palimento et al. (35)       2003    52   84%       89%
Kairaluoma et al. (10)      2003    60   2.3       2
Krska et al. (65)           2003    50   NS        NS
Wilson et al. (39)          2002    99   NS        NS
Senagore et al. (67)        2004   156   NS        NS
Kraemer et al. (75)         2005    50   10        9
Lau et al. (31)             2004    24   NS        NS
Ortiz et al. (33)           2005    31   NS        NS
Van de Stadt et al. (63)    2005    40   9.1       7.6
Mattana et al. (19)         2007   100   NS        NS
Sabanci et al. (76)         2007   100   96%       80%
Ascanelli et al. (77)       2005   100   80%       96%

                            Recurrence

Author                      EH    PPH   Follow-up

Ho et al. (30)              NS    NS    3
Rowsell et al. (23)         NS    NS    1.5 ([dagger])
Boccasanta et al. (37)      NS    NS    20
Shalaby & Desoky (73)       0     0     12
Correa-Rovelo et al. (28)   0     1     14
Pavlidis et al. (34)        NS    NS    12
Basdanis et al. (26)        0     3     24
Hasse et al. (38)           NS    NS    12
Racalbuto et al. (41)       0     6     NS
Bikhchandani et al. (40)    2     4     11
Chung et al. (27)           0     0     6
Gravie et al. (74)          0     2     24
Goulimaris et al. (18)      NS    NS    6
Helmy (72)                  NS    NS    3
Khalil et al. (48)          NS    NS    6
Mehigan et al. (22)         NS    NS    2.5 ([double dagger])
Brown et al. (36)           NS    NS    2.5
Ganio et al. (24)           1     2     87 ([section])
Hetzer et al. (29)          1     1     12
Ortiz et al. (32)           0     7     12
Cheetham et al. (47)        0     3     8
Palimento et al. (35)       NS    NS    6
Kairaluoma et al. (10)      0     0     12
Krska et al. (65)           NS    NS    NS
Wilson et al. (39)                      NS
Senagore et al. (67)        NS    NS    NS
Kraemer et al. (75)         NS    NS    2.5
Lau et al. (31)             NS    NS    2
Ortiz et al. (33)           0     8     12
Van de Stadt et al. (63)    0     8     46
Mattana et al. (19)         NS    NS    73
Sabanci et al. (76)         1     1     24
Ascanelli et al. (77)       0     2     12

Figures in parentheses are standard deviation or range.

* Numbers refer to satisfaction scores; percentages refer to
proportion of patients satisfied with procedure. Some studies
reported satisfaction as similar in both groups but did not
give figures.

([dagger]) Follow-up completed by Au Yong et al. (20)

([double dagger]) Follow-up completed by Smyth et al. (21)

([section]) Follow-up completed by Ganio et al. (25)

Table V. Comparison of complications and residual
symptoms in 24 studies comparing EH and PPH

                                        EH (N=1 170)   PPH (N=1 200)

Complications and residual symptoms     N (%)          N (%)
  Nausea and vomiting                   3 (0.2)        4 (0.3)
  Sepsis                                2 (0.2)        1 (0.1)
  Wound dehiscence                      43 (4)         2 (0.2)
  Urinary retention                     73 (6)         82 (7)
  Faecal impaction                      23 (2)         9 (1)
  Tenesmus                              4 (0.3)        10 (1)
  Thrombosis of residual haemorrhoids   6 (0.5)        14 (1)
  Thrombosed external 'piles'           3 (0.2)        8 (0.6)
  Urgency                               11 (0.9)       18 (1.5)
  Pruritus                              50 (4)         28 (2)
  Persistent pain                       30 (3)         28 (2)
  Anal fissure                          11 (0.9)       12 (1)
  Anal fistula                          1 (0.1)        0
  Skin tags                             50 (4)         66 (5.5)
  Oedema                                10 (1)         10 (1)
  Residual haemorrhoids                 5 (0.4)        20 (1.7)
  Soiling                               73 (6)         23 (1.9)
  Stenosis                              29 (3)         19 (2)
  Bleeding within 24 hours              11 (1)         32 (3)
  Bleeding after 24 hours               54 (5)         30 (3)
  Bleeding undefined                    46 (4)         37 (3)
  Incontinence (undefined)              14 (1)         10 (1)
  Incontinence (solids)                 4 (0.3)        4 (0.3)
  Incontinence (liquids)                9 (0.8)        3 (0.3)
  Incontinence (gas)                    20 (2)         14 (1)
  Total incontinence                    47 (4)         41 (2.6)
    Total morbidity                     567 (48%)      408 (34%)
Recurrence
  Recurrent haemorrhoids                3              6
  Recurrent prolapse                    1              31
  Recurrent symptoms                    7              12
  Undefined recurrence                  3              6
    Total recurrence                    14 (1%)        55 (4%)

Information obtained from all the studies comparing the two procedures.
N = total number of patients with complication.
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