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| 번호 | 제목 | 등록일 | 조회수 |
|---|---|---|---|
| 108 | Prospective Study of Factors Affecting Postoperative Pain and Symptom Persistence After Stapled Rectal Mucosectomy for Hemorrhoids [2003년 7월 DCR] | 2011-11-17 | 3487 |
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A Need for Preservation of Squamous Epithelium
Jose´ M. Correa-Rovelo, M.D.,* Oscar Tellez, M.D.,* Leoncio Obrego´n, M.D.,*Ximena Duque-Lo´pez, M.Sc.,§ Adriana Miranda-Go´mez, M.D.,*Rau´ l Pichardo-Bahena, M.D.,† Manuel Mendez, M.D.,* Segundo Moran, M.D.‡§
From the *Colon and Rectum Clinic, †Pathology Department, and ‡Gastroenterology Clinic, Me´dica Sur Hospital, and §Nutritional Epidemiology Research Unit, Mexican Institute of Social Security, Mexico City, Mexico
PURPOSE: The purpose of the study was to determine the variables associated with postoperative pain and the clinical response of patients with uncomplicated hemorrhoidal disease treated with stapled rectal mucosectomy in the medium term.
METHODS: Patients with Grade II to IV, uncomplicated hemorrhoidal disease who underwent stapled
rectal mucosectomy were prospectively included. The basal characteristics of the population were evaluated and level of stapling and placement of hemostatic suture determined. Histologically, the type of resected epithelium and presence of muscle fibers was evaluated. Postoperative pain was evaluated by means of a visual analog scale. Complications and clinical response were evaluated. RESULTS: One hundred patients with a mean age of 43.9 years were included. Only columnar epithelium was resected in 48, transitional epithelium in 47, and squamous epithelium in 5 patients. Smooth muscle fragments were found in 55 patients, and, in 12 of these, fibers from the external muscular layer of rectum were also seen. Follow-up was 12.6 +/- 3.4 (range,7–24) months. A total of 79 patients were completely asymptomatic at the end of follow-up. Resected squamous epithelium was associated with a higher postoperative pain level in the multivariate analysis (coefficient beta = 1.16 (95 percent confidence interval, 0.08–2.24); P = 0.035). CONCLUSIONS: Rectal mucosectomy with stapler is an effective method for the treatment of uncomplicated prolapsing hemorrhoidal disease. Intensity of postoperative pain was associated with the type of resected epithelium. This suggests that low transection of hemorrhoids must be avoided.
Currently, one of the most novel treatments for hemorrhoidal disease (HD) is anopexy, or rectal
mucosectomy, with a circular stapler. This consists of the relocation of prolapsing hemorrhoids to their anatomic place within the anal canal by means of a circumferential resection of the redundant mucosa situated above the hemorrhoids. Moreover, the blood flow from the different submucosal branches of hemorrhoidal arteries is interrupted by stapling. Stapled rectal mucosectomy (SRM) has received more acceptance because it is less painful and disabling than a conventional hemorrhoidectomy, and because the procedure does not involve any surgery to the sensitive anal mucosa below the dentate line. However, few studies have addressed the clinical results in medium-term and long-term follow-up.
According to recent reports, SRM can be considered a relatively safe and efficient procedure. However,
an association between muscle incorporation in the resected doughnut and the appearance of persistent and severe anal pain and fecal urgency has been reported. Another author has advocated the frequent inclusion of the longitudinal muscle of the rectum and the fibers of the internal anal sphincter. Others have reported additional serious, although rare, complications. There are some technical issues regarding SRM that should be considered by the surgeon. These should be analyzed for the proper application of the technique in the selected patient. Noteworthy points
among these include the ideal level for stapling (either high or low transection); the placement of sutures in some patients to achieve a satisfactory hemostasis; the type of resected epithelium; and the possibility of including smooth muscle, mainly at the level of the internal anal sphincter, as well as the external muscle layer of the rectum. Therefore, in addition to biologic variability, inherent variations are presented to the surgeon using SRM, the effects of which have not been well established in the postoperative period nor the medium and long term. The objective of this study was to determine the variables associated with the postoperative pain level during the first 24 hours after surgery and, in the medium term, the clinical results after the SRM in patients with uncomplicated hemorrhoidal disease (UHD). |
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