Transcript Opinioni a confronto in coloproctologia LONGO o MILLIGAN

Opinioni a confronto in coloproctologia
LONGO o MILLIGAN-MORGAN?
Angelo Stuto
S.O.C. Chirugia Generale 2
Az. Osp. “S.M.A.” Pordenone
[email protected]
Conclusion
1. Hemorrhoidal Disease is Caused by
Prolapse
2. PPH treats Hemmorhoids by Fixing the
Prolapse
3. PPH is Less Painful and Better Respects
the Anatomy and Physiology when
compared to Hemorrhoidectomy
Hemorrhoidal Treatments
Fixes Prolapse
• Rubber Band Ligation
• Doppler (?)
• No Doppler techniques
• PPH
Does not Fix Prolapse
• Milligan-Morgan
• Ferguson
• Parks
• Laser
• Cryotherapy
• ……etc……
Longo primi anni ‘90
[email protected]
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
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
NICE & PPH
NICE review 2006
• Independent analysis by Health
Economics Unit, University of York
• Meta-analysis
– 27 RCTs
– 2279 patients
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 metaanalysis
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 metaanalysis
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 metaanalysis
Results: pain
10
9
SH
CH
Predicted SH
Predicted CH
8
Mean VAS Score
7
6
5
4
3
2
1
0
0
5
10
15
20
Number of days post-operatively
• Short-term: less pain following PPH
• Long-term: few patients; no difference
25
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)
Results: complications
• No difference in short-term or long-term
– Anal stenosis/stricture
– Incontinence
– Faecal urgency
– Urinary retention
– Septic complications
PPH & Prolapse
Follow-up Outcome
OR
95% CI
P-value
Overall
SH
worse
5.18
1.7315.50
0.003
Shortterm
No diff
3.20
0.7114.45
0.13
Longterm
SH
worse
4.34
1.6711.28
0.003
PPH: procedure costs
Resource use
Costs
Unit cost
(£)
CH
SH
CH
SH
Theatre time
(min)
8.27
29.2
15.5
242
128
Length of
Stay
(days)
256
2.7
1.4
681
366
Device
420
0
1
0
420
923
914
TOTAL PROCEDURE
COSTS
PPH device costs offset by reduced length of stay
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”.
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?!
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 resurgery is considered
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
Distal Rectal Redundancy
Rectocele
Internal prolapse
Haemorrhoids with
Internal prolapse
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
F. Hetzer, A. Senagore in Transanal
Stapling approach for anorectal
prolapse ed. Springer 2009
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