Clinical Question: 

A 44 yo male patient presents to the surgery clinic for evaluation of internal Grade III Hemorrhoids. The hemorrhoids have become painful and interfere with daily activities. Surgery is indicated and the physician decides that the patient is a good candidate for stapled hemorrhoidectomy. 

Search Question: 

Does the use of stapled hemorrhoidectomy deliver more rapid hemorrhoid removal but present with more post-op complications than excisional hemorrhoidectomy?

PICO Question:

Search Strategy:

For this PICO search, I included randomized controlled trials and retrospective cohort studies. The meta-analyses and systematic analyses found were all over ten years old. For this reason, I prioritized recent data over level of study to draw the most relevant and data-driven conclusion. Although RCTs and retrospective cohort studies are not the highest level of study, I believe more recent data with contemporary research design, medical settings, and protocols would yield the best data. Initially,  I only used the search term, “stapled hemorrhoidectomy” to see what results came up as I believed the procedure to be very specific.  However, this search term yielded vague results on the topic of stapled hemorrhoidectomy without comparing it to the traditional excisional method. This led me to use the search terms, “stapled hemorrhoidectomy traditional hemorrhoidectomy” and “stapled hemorrhoidectomy conventional hemorrhoidectomy” to find higher- yielding results. 

This created a pool of retrospective cohort studies and randomized control trials to choose from. I chose the first two articles as one assessed short-term results while the other evaluated long-term effects. I then chose article 3 as it also looked into long-term results, but broke down each adverse effect specifically by percentage. Finally, article 4 was included as it strategically divided participants exactly in half as to which group received what procedure and ensured that surgical methods remained the same. This ensured the bias was minimized to produce high-yielding results. 

RESULTS FOUND :

Article 1 : Short term results of stapled versus conventional hemorrhoidectomy within 1 year follow-up

Article 2 – Long-Term Results After Stapled Hemorrhoidopexy Alone and Complemented by Excisional Hemorrhoidectomy : A Retrospective Cohort Study

Article 3 – Comparison of stapled haemorrhoidopexy with traditional excisional surgery for haemorrhoidal disease (eTHoS): a pragmatic, multicentre, randomised controlled trial

Article 4 : Stapled hemorrhoidopexy versus open hemorrhoidectomy: a comparative study of short term results

Summary of the Evidence:

Conclusion(s):

Article 1 (Mir, P) compared the use of stapled hemorrhoidectomy and traditional hemorrhoidectomy over a period of one year. Its results concluded that patients who received stapled hemorrhoidectomy experienced less pain and need for morphine immediately after post-op. However, patients who received stapled hemorrhoidectomy experienced a greater rate of recurrence by the end of one year. 

Article 2 (Araujo, S) compared the use of stapled hemorrhoidectomy by itself versus the use of stapled hemorrhoidectomy in conjunction with traditional excisional hemorrhoidectomy.  The study found that the combination of stapled hemorrhoidectomy and the traditional method yielded the most positive results. This technique lowered recurrence rates and lowered the need for additional medical or surgical interventions during the post-op period.

Article 3 (Watson, A) compared the post-op outcomes and cost of stapled hemorrhoidectomy and traditional excisional hemorrhoidectomy. The study determined that both procedures presented with similar rates of adverse effects. However, stapled hemorrhoidectomy was only as successful as the skill of the surgeon and also cost over three-hundred dollars more than the traditional method. 

Article 4 (Sachin, ID) assessed stapled hemorrhoidectomy versus traditional hemorrhoidectomy over a period of 6 months. The conclusion was that stapled hemorrhoidectomy resulted in shorter hospital stays, less post-op complications, less pain, and reduced need for analgesics. At the end of 6 months, the 100 participants demonstrated no recurrence, residual prolapse, or incontinence. 

Overall, these 4 studies suggest that stapled hemorrhoidectomy presents with less adverse effects intraoperatively and in a short-term period. However, stapled hemorrhoidectomy presented with greater complications such as recurrence after a one year period. Stapled hemorrhoidectomy also demonstrated to be a more expensive option that is limited by the technique of the surgeon. For these reasons, my overall conclusion based on this study is that traditional hemorrhoidectomy remains the preferred treatment for excising hemorrhoids. To strengthen the findings of these studies, a systematic review may be conducted that include studies conducted over a longer period of time. 

Clinical Bottom Line:

I would weigh Article 3 : Comparison of stapled haemorrhoidopexy with traditional excisional surgery for haemorrhoidal disease (eTHoS): a pragmatic, multicentre, randomised controlled trial as the strongest study. This is because it was a large randomized control trial that studied the adverse effects in the greatest detail. It specifically broke down each adverse effect by category and observed for its prevalence. Furthermore, I believe this study brought valuable insight compared to the other two studies in that it evaluated the cost for other operations as well. When comparing procedures, it is easy to only consider the procedural outcomes without assessing the financial considerations of the patient. In doing so, Article 3 provided a holistic perspective of the procedural outcome to recommend traditional hemorrhoid excision as the continued gold standard of treatment.

Next, I would select Article 1 : Short term results of stapled versus conventional hemorrhoidectomy within 1 year follow-up, as the next strongest study. It studied the PICO question at hand over a 1 year interval. This allowed for the most immediate assessment of the post-op period for any complications. This study demonstrated that although stapled hemorrhoidectomy presented with the least amount of immediate post-op adverse effects, the procedure caused more patients to require additional medical treatment by the 1 year mark. 

Following Article 1, I would weigh Article 4 :Stapled hemorrhoidopexy versus open hemorrhoidectomy: a comparative study of short term results as the next strongest study. This study ensured that the surgical techniques such as analgesia, patient positioning, and use of antibiotics remained the same across patients. It also required that patients to have never received a hemorrhoidectomy in past or experience concurring anal complications such as fissures or fistulas. However, this study was severely limited in that it had a small pool of participants compared to the other studies and only looked into the short-term results over a period of six months. 

Last, Article 2 : Long-Term Results After Stapled Hemorrhoidopexy Alone and Complemented by Excisional Hemorrhoidectomy : A Retrospective Cohort Study, presents as the weakest study. This is due to the fact that it did not look at stapled surgery and traditional excision separately. Instead, stapled surgery was observed as an additional procedure when used alongside traditional excision. This makes it slightly more difficult to decipher how much of an impact stapled hemorrhoidectomy could make on its own. However, the article still provides valuable data that stapled hemorrhoidectomy may be best used as an adjunct technique rather than a standalone surgical method. 

Overall, stronger studies could have been included to draw a more definitive conclusion. But the current meta-analysis and systematic analyses found in the initial PICO search were over 10 years old. I would argue that this question of study should be revisited to see if modern advances in healthcare setting and approach and stapled hemorrhoidectomy device design have influenced the outcomes of the procedure.This could be achieved by pooling together another systematic review using retrospective cohort studies and randomized control trials performed within the last ten years.

The clinical bottom line is that stapled hemorrhoidectomy does not present as a more effective surgical procedure in comparison to traditional excision based on current available studies. Although stapled hemorrhoidectomy may present with less pain, bleeding, and use of analgesic during the immediate post-op care, patients were found to experience a larger number of adverse effects, recurrence, and need for additional medical attention over a longer period of time. For the patient presented, I would recommend that the patient receive a traditional excisional hemorrhoidectomy as this has been the gold standard treatment and continues to demonstrate safe and effective results. Furthermore, the socioeconomic background of the patient should be considered as the traditional method is less expensive and presents as a more financially viable option.  

Magnitude of any effects
These 3 articles show that the effect is high. All three showed significant benefits in short-term outcomes with the use of stapled hemorrhoidectomy. However, two of the four studies highlighted statistically significant findings in that stapled hemorrhoidectomy presents with greater recurrence rates in long-term outcomes and higher costs. This suggests that stapled hemorrhoidectomy may achieve more positive short-term effects, but with consequences later down the road. This suggests that stapled hemorrhoidectomy should still be used with caution when applying a holistic perspective of the procedure’s outcomes.

Clinical significance (not just statistical significance)

I would argue that the clinical significance of these findings are high. Hemorrhoids are, unfortunately, a common complication found among the general public, affecting both men and women. For this reason, the search for a more effective and efficient procedure is enticing. However, the studies show that the use of new technological devices may not, in fact, benefit patient outcomes. The studies show a strong statistical correlation that stapled hemorrhoidectomy may improve intraoperative and short-term post operative outcomes, but produce more long-term consequences such as recurrence rates. These findings demonstrate how surgical technique outweighs technological advances in patient outcome for the PICO case presented. 

Any other considerations important in weighing this evidence to guide practice  

Based off the findings in the included articles, I believe a larger sample size with a standardized research design over a longer period of time is needed to establish the efficacy of stapled hemorrhoidectomy versus traditional excisional hemorrhoidectomy. For example, each of the studies had strengths that the others lacked. An ideal study design would include the positive aspects from all three. This would include a large sample size, standardized surgical treatment (i.e. patient position, use of anesthetic, dosage of post-op antibiotics), use of the same surgeon, and a follow-up of greater than one year with clinical visits. This design would ensure that additional factors are minimized so that the Participants could be categorized by different genders and age groups when comparing the two types of surgery. In doing so, the study can better gauge the outcomes for a specific population rather than a generalized assessment. These will allow for more specific classification to increase the weight of the study.