Abstract
BACKGROUND: Transanal stapled procedures are increasingly being used. Several postoperative complications can be referred to their application, including those related to the presence of retained staples at the level of the staple line.

OBJECTIVE: This study was conducted to assess whether the removal of the retained staples is a useful approach to improve some of the most common postoperative complications of these surgical techniques.

DESIGN: This is a retrospective study.

SETTINGS: The study was conducted at the One-Day Surgery Unit of St. Andrea Hospital.

PATIENTS: All of the patients who underwent a stapled transanal procedure from January 2003 to December 2011 were included in the study. Patients included in the study were followed postoperatively for 1 year after surgery to identify the presence of retained staples.

INTERVENTIONS: If identified, the retained staples were removed endoscopically or transanally.

MAIN OUTCOME MEASURES: After the staple removal, patients were followed with biweekly office visit for 2 months to evaluate the progression of symptoms.

RESULTS: From the 566 patients included in the study, 165 experienced postoperative complications, and in 66 of these cases, retained staples were found and removed. With the removal of retained staples, symptoms were almost all resolved or improved. In only 1 case did the retained staples removal not modify the symptoms.

LIMITATIONS: The study design may have introduced potential selection bias. In addition, the study was limited by the lack of a specific questionnaire for the evaluation of symptoms improvement.

CONCLUSIONS: The removal of the retained staples is an efficacious and safe procedure to solve or improve postoperative complications and should be always considered.
 

Transanal stapling techniques have become increasingly popular in the last decade to treat some of the most common anorectal diseases, such as hemorrhoidal prolapse, rectal prolapse, obstructed defecation syndrome, and rectocele.

Despite the advantages of stapled hemorrhoidopexy (SH), stapled transanal rectal resection (STARR), and Transtar procedure (TP) in terms of low postoperative pain, short hospital stay, early return to normal life activities, and low postoperative complication rate, the transanal stapling techniques are burdened by some troublesome postoperative complications.^1–3

Tenesmus, urgency, postoperative pain, and bleeding are the most common complications after transanal stapling procedures and, in some cases, are related to the retention of some staples on the anastomotic ring. The removal of retained staples seems to lead to the resolution of the symptoms or at least to their significant improvement, as reported by some authors.^4–9 This, unfortunately, is rarely mentioned as a treatment option for complications after SH, STARR, or TP. To test whether the removal of the retained staples really allows for improvement of some of the most common postoperative complications, we conducted a retrospective analysis of a prospectively maintained database aimed to evaluate the benefits of removing the staples.

MATERIALS AND METHODS

We conducted a prospective study evaluating the data of all of the patients who underwent a stapled transanal procedure at our institution from January 2003 to December 2011. Patients who underwent the stapling procedure associated with another proctologic procedure for a concomitant anorectal disease were excluded from the study. According to our protocol, all of the patients were preoperatively evaluated with anorectal manometry and, if they were >40 years of age, with colonoscopy to assess the absence of anal sphincter deficiency and endoluminal colonic disease.

Surgical Techniques

The SH was performed according to the original technique using a PPH 01 or PPH 03 stapler (Ethicon Endosurgery, Inc., Cincinnati, OH).¹⁰ The STARR was performed with the use of 2 circular staplers implementing 3 separate one-half pursestrings (180°) per side.¹¹ The STARR was performed using the STARR-One technique, which involves the use of a high-volume circular stapler (Chex CPH34 HV, Frankenmann, Shuzhou, China) and the placement of 6 parachute stitches on the apex of the prolapse, so as to introduce a greater amount of prolapsed tissue within the housing of the stapler.¹² The TP was performed using a Transtar CCS-30 (Ethicon Endosurgery, Inc) stapler according to a modified technique, wherein the longitudinal opening of the prolapsed tissue was created using an electric scalpel between 2 Kocher clamps and not by application of a Transtar stapler.¹³

Staple Removal

The exposed staples were removed by plucking them out bluntly using a transanal approach with a disposable circular anal dilator or endoscopically with foreign body forceps (Fig. 1). In the presence of bleeding, some hemostatic stitches were placed. If not needed, we preferred not to resect the scar tissue around the staple line to avoid the risk of rectal perforation and sepsis.

 

FIGURE 1. Staple ring with retained staples (arrow).

Outcome Evaluation

All of the patients were followed postoperatively in accordance with our standard protocol for 1 year after surgery, with outpatient visits 7 and 30 days after surgery and thereafter at 3, 6, and 12 months.

We investigated the complications that occurred in the postoperative period. When tenesmus, urgency, pain, or bleeding was present at 3 months after the procedure, the patients underwent an anoscopy or rectoscopy to identify the presence of retained staples. In this case, we usually treated these patients with local steroid application and with the removal of staples if the symptoms persisted until 6 months. Patients with postoperative pain that was localized at the level of 1 or more retained staples or with bleeding from an inflammatory pseudopolyp or granuloma at the site of the retained staples underwent the removal of the staples at the 3-month visit.

After the removal of retained staples, the patients were followed up with 1 visit every 2 weeks for 2 months to evaluate the disappearance or the improvement of symptoms. The biographic and operative data of the patients were collected in a specific digital database.

RESULTS

Between January 2003 and December 2011, 661 patients were subjected to transanal stapling procedures for anorectal disease. Ninety-five patients were excluded because they underwent a transanal stapling procedure associated with another proctologic procedure. Finally, 566 patients were included in the study. They included 344 women and 222 men with an mean age of 53 ± 16.4 years and a mean BMI of 25.1 ± 3.5 kg/m². A total of 308 patients (54.4%) underwent SH, 78 (13.8%) underwent STARR, and 180 (31.8%) underwent TP (Table 1). Postoperative tenesmus, urgency, rectal heaviness, mucus discharge, pain, or bleeding was reported by 165 patients; in 78 of these patients the symptoms disappeared spontaneously in 2 to 4 weeks. At a 3-month follow-up visit, 65 patients continued to report tenesmus, urgency, rectal heaviness, or mucus discharge and were treated with steroid local therapy, whereas 14 patients reported chronic pain and were subjected to staple removal. These last 14 patients with chronic pain reported that, immediately after staple removal, the symptomatology significantly improved, with complete pain disappearing within 2 weeks.

TABLE 1. Characteristics of patients

Of the 65 patients, only 51 reported that tenesmus, urgency, rectal heaviness, or mucus discharge was still present at the 6-month follow-up visit. In 44 of these 51 patients, 1 or more retained staples were identified and then removed. The symptoms were resolved in 28 patients (63.7%) and improved in 15 (34.1%). In only 1 case did the retained staple removal not modify the symptoms, which persisted at the 12-month visit. None of the 15 patients with improved symptoms after retained staple removal showed symptoms at the 12-month follow-up visit.

Of the remaining 7 patients in which there were no identified retained staples, in 4 the symptoms spontaneously disappeared within 12 months of the intervention. The other 3 patients were subjected to a defecography for the suspect of rectal stenosis (hourglass rectum), which was identified in 1 of patient and treated by resection of the staple ring and manual reanastomosis. In the remaining 2 patients, the defecography showed a puborectalis paradox contraction that was treated with biofeedback therapy, resulting in complete resolution of symptoms after 6 and 8 months of therapy.

The remaining 8 patients in this study experienced persistent minor rectal bleeding for >3 months after surgery. In these patients we found 1 or more polyps at the site of the retained staples. The polyps were endoscopically removed, together with the staples; this maneuver completely stopped the bleeding. Finally, 1 or more retained staples were removed in 66 cases (Table 2).

 

TABLE 2. Study results

 

 

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DISCUSSION

The widespread application of transanal stapling techniques has allowed significant for improvement in the therapy of hemorrhoidal disease, rectal prolapse, obstructed defecation syndrome, and rectocele. However, it also has led to the onset of new types of postoperative complications related to the use of metal staples. It is a common belief that the staples do not remain after transanal staple procedures, because they should shed during the healing process of the anastomosis. Unfortunately, as many surgeons have been able to observe, often the staples are still present at visits after 6 months. This is probably related to the deep anchorage of the staples in the rectal wall, caused by the low possibility of resecting only the mucosa and submucosa during the SH and the fact that a full-thickness resection of the rectal wall was performed during the STARR or TP. In fact, as demonstrated by Garg et al,⁴ in almost all procedures, staples are secured deep in the muscular layers of the rectal wall, and it is unlikely that these will be completely expelled during the healing process.

Staples that emerge out of the mucosa may led to chronic inflammatory reaction. This process may cause the formation of inflammatory polyps and granulomas and lead to tenesmus, urgency, anal irritation, persisting itching, excess mucus discharge, and rectal heaviness that are usually reported after a transanal stapling procedure.⁵

Tenesmus and urgency, as well as rectal heaviness and mucus discharge, usually disappears within the first 2 to 3 weeks after surgery.^1–3 A persistence of these symptoms for >3 months should raise suspicion of the presence of chronic inflammation of the anastomosis and thus the possible presence of retained staples.⁶ In our series, the persistence at the 6-month follow-up visit of tenesmus, urgency, rectal heaviness, and mucus discharge and their resistance to steroid therapy has resulted, in almost all of the cases (86%), in the identification of 1 or more retained staples surrounded by an inflammatory reaction. The removal of these staples led to complete resolution of symptoms in 28 patients (63.7%) and to the improvement of symptoms in 15 patients (34.1%). Only 1 patient (2.2%) experienced no benefits from the removal of staples. Similar results were reported by De Nardi et al,⁷ who obtained the resolution of tenesmus, urgency. and pain after removal of some retained staples in 1 patient. Pescatori and Zbar⁸ reported the improvement of urgency after the removal of retained staples in a 58-year-old man who underwent STARR. In addition, Garg et al⁹ observed the improvement of rectal heaviness and inflammation after the removal of retained staples.

On the other hand, Kam et al¹⁴ performed the resection of the complete staple ring and scar tissue, followed by manual anastomosis, to treat urgency and incontinence. However, in these patients the urgency and incontinence were not related to the presence of retained staples but rather to an excessive scar reaction with subsequent stenosis of anastomosis that led to the creation of an hourglass-shaped rectum. This caused a decrease in rectal distensibility and volume thresholds for sensation and was associated with urgency and/or increased stool frequency.¹⁵,¹⁶

Postoperative pain is another severe complication after transanal stapling procedures. This is related to several possible causes, including placement of the staple line close to the dentate line, placement of hemostatic stitches, anal hypertone, or concomitant anal fissure, as well as suture dehiscence and/or infection.^1–3,¹⁷–26

The puborectalis muscle involvement along the staple line and the chronic stimulation of the rectal wall nerve spindles by 1 or more staples or by the inflammatory reaction around it may also lead to chronic postoperative pain. Usually, as we observed in our series, if the pain is localized to a limited region of the rectum, it is related to the presence of retained staples. In these cases, the patients are able to precisely locate the trigger point of the pain, and removal of the staples completely resolves the pain. In our series, in all 14 patients of the with localized rectal pain in which we identified and removed 1 or more retained staples, the pain was completely relieved in a few days.

Brusciano et al²¹ reported the resolution of persistent anal postoperative pain and bleeding after removal of the staples. In this series, the removal of retained staples was performed in 6% of all SH procedures with good outcomes.²¹ In addition, De Nardi et al⁷ reported the resolution of pain after removal of retained staples located 2 cm above the dentate line. Similar results were reported by Ravo et al²⁷ after SH and by Boffi²⁸ after STARR.

Another complication frequently related to the presence of retained staples is the persistence of postoperative bleeding. Usually the bleeding is scarce but recurrent, and it can last for months after surgery.²⁹ In our series we found, at the level of the anastomotic ring, 1 or more inflammatory polyps grown at the level of the retained staples. The resection of the polyps and the removal of the staples led to complete resolution of the bleeding. Quah et al³⁰ reported 2 cases of persistent bleeding that ended after removal of retained staples in patients who underwent SH. Drummond and Wright³¹ reported the case of a patient with intermittent rectal bleeding >4 years after SH who was effectively treated with staple removal. In addition, Brusciano et al²¹ reported a case of postoperative persistent rectal bleeding after SH that was treated with the removal of staples. Fondran et al⁵ recommended the polypectomy of inflammatory polyps to treat late bleeding after SH. Others authors reported the resolution or improvement of rectal bleeding after retained staple removal.¹²,³²

This study is limited in that it is a case series and therefore probably has the constraint of an observational bias. We have attempted to avoid this bias by including all of the patients with a surgical indication for stapling transanal techniques. Also, the lack of a control group makes it difficult to draw definitive conclusions on the efficacy of removal of retained staples. In this study, the anal exams to look for retained staples were only performed on patients with certain postoperative symptoms, and this may have introduced a selection bias. The other weakness of this study is the evaluation of symptom improvement without the use of a specific questionnaire, which may have introduced a potential bias.

CONCLUSION

After transanal stapled procedures, the presence of retained staples should always be suspected in the case of tenesmus, urgency, pain, or bleeding for >3 months after surgery. The removal of the retained staples is an efficacious and safe procedure to solve or improve the symptoms and should be always considered. A prudent conduct and an interval of 3 to 6 months between the intervention and the removal of staples should be considered to avoid unnecessary interventions and to reduce the risk of complications. Additional studies including a larger series of patients are needed to confirm this statement.

REFERENCES