2 The procedure
2.1.1 Circular stapled haemorrhoidectomy is used to treat internal haemorrhoids, which develop when cushions of vascular tissue in the anus undergo pathological change. Haemorrhoids may prolapse and cause bleeding, faecal soiling, itching and occasionally pain.
2.2.1 In circular stapled rectal haemorrhoidectomy, a stapler is used to excise an annulus of rectal mucosa above the haemorrhoids. This reduces the size of internal haemorrhoids by interrupting their blood supply, and reducing the available rectal mucosa with the potential to prolapse. By contrast, conventional surgical haemorrhoidectomy involves excision of haemorrhoidal tissue, anoderm and perianal skin.
2.3.1 The studies suggested that patients had less pain and returned to normal activity more quickly after stapled haemorrhoidectomy than after conventional haemorrhoidectomy. In one randomised controlled trial with 84 patients, th average time of return to work was 6 days after the circular stapled technique, compared with 15 days after conventional surgery. For more details refer to the 'Sources of evidence' section.
2.3.2 The Specialist Advisors stated that circular stapled haemorrhoidectomy was relatively new, but that an increasing number of surgeons were using this approach. The Advisors considered stapled haemorrhoidectomy to be as effective as the surgical alternative. They noted that there were limited long-term data, and that the durability of the procedure was therefore unclear.
2.4.1 The studies suggested a lower overall postoperative complication rate with circular stapled haemorrhoidectomy than with conventional haemorrhoidectomy. A systematic review published in 2001 indicated a significant reduction in the risk of bleeding during the first 2 weeks after the procedure. For more details refer to the 'Sources of evidence' section.
2.4.2 The Association of Coloproctology's consensus document stated that adverse events were related to the possibility of a full thickness excision to the rectal wall, with the potential for injury to the internal anal sphincter. In addition, stretching of the anal sphincter by the stapler head may, in theory, cause injury.
2.4.3 The Specialist Advisors suggested that most of the safety concerns were theoretical and that many of them were not supported by the trials that have been published.
2.5.1 It was noted that long-term data were lacking and that the Association of Coloproctology of Great Britain and Ireland is undertaking an audit on this procedure. Surgeons doing this procedure are strongly encouraged to include patients in this audit.