Hemorrhoids: Surgery Beats Stapling

Recurrence Greater With Stapling, Review Shows

By Salynn Boyles
WebMD Health News

Reviewed By Louise Chang, MD
on Friday, October 20, 2006

Oct. 20, 2006 - An increasingly popular, nonsurgical treatment for hemorrhoids is not as effective in the long run as traditional surgery, a review of the research shows.

Once known as piles, hemorrhoids are one of the most common and least talked about medical complaints. About half of all Americans get them at some point.

Surgical removal was once the only option for large hemorrhoids that could not be adequately managed with topical therapies, but newer treatment options include rubber bands and staples that choke off their blood supply.

A review of the research, published last year, suggested surgery is a better long-term option for severe hemorrhoids than the banding procedure, known as rubber band ligation.

Now, a separate study shows the same to be true for hemorrhoid stapling.

Both research reviews were sponsored by The Cochrane Collaboration, an international, non-profit group that provides independent assessments of current medical practices.

The new findings were published in the latest issue of The Cochrane Library.

More Recurrences With Stapling

Hemorrhoid stapling has been growing in popularity since its introduction in the U.S. in the late 1990s, largely because it is viewed as a far less painful alternative to surgery.

Early studies found stapling to be as effective as surgery, but colon and rectal surgeon David Thompson, MD, FACRC, says this is not his experience among patients with severe hemorrhoids.

The University of Texas Medical School associate professor of surgery tells WebMD he does not consider stapling an appropriate treatment for patients with very painful internal and external hemorrhoids.

"I have seen many cases where patients with these severe hemorrhoids end up coming to us after having stapling because they are still having trouble," he says.

7 Studies Reviewed

The newly published review included seven trials with a total of 537 patients who had either hemorrhoid stapling or surgery. The studies were published between 1998 and May of this year, with patients followed as long as three years.

The review showed that patients who had the stapling procedure were significantly more likely to have their hemorrhoids come back than surgical patients.

Of the 269 stapling patients, 23 had recurrences, compared with four of 268 surgical patients.

Within a year of treatment, more patients who had stapling also developed internal hemorrhoids that protruded outside the anus, a condition known as prolapse.

Stapling patients did experience less pain than surgical patients, and they reported slightly less itching and bowel movement urgency. But these differences did not reach the level of statistical significance.

The 'Gold Standard'

The researchers concluded that both procedures are relatively safe, but patients need to be made aware of the differences in outcomes between the two approaches.

"If hemorrhoid recurrence and prolapse are considered the most important clinical outcomes, then conventional (surgery) remains the 'gold standard' treatment for hemorrhoids," Jayaraman S. Colquhoun, PhD, and colleagues write.

The reviewers note that stapling may still prove to be a better option than surgery for some.

"One of the questions that needs to be answered is, 'Are patients willing to accept a greater likelihood of hemorrhoid recurrence and symptom recurrence if the intervention is more tolerable in the short term?'" they write.

Thompson says even if this is the case, surgery is still a better option for patients with severe hemorrhoids because it is less risky.

"I personally know of at least three cases in my area where patients who had stapling ended up needing colostomies due to complications," he says. "I have been doing hemorrhoid surgery for more than 20 years, and I have never had to give a colostomy because of complications."

SOURCES: Colquhoun, J. Cochrane Database of Systematic Review, Oct. 18, 2006; issue 4. David Thompson, MD, FACRC, colon and rectal surgeon; associate professor of surgery, University of Texas Medical School at Houston. WebMD Health News: "Which Hemorrhoid Procedure Is Best?"

© 2006 WebMD Inc. All rights reserved.


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