Comparative Evaluation of Surgical Treatment of Chronic Hemorrhoids Using Mechanical Suture and Closed Standard Hemorrhoidectomy

The dissertation is devoted to a comparative evaluation of two variants of closed surgical treatment of chronic hemorrhoids: using mechanical suture with the UDO-38 device and closed standard hemorrhoidectomy. The research is based on the treatment outcomes of 116 patients operated on during 2002–2004, with outcomes traced for up to three years. The work presents a comprehensive analysis: clinical, cytological, microbiological, ultrasonic (transperineal-transvaginal), and economic. The scientific novelty lies in the first-time comparative analysis of immediate and long-term results of two methods of closed hemorrhoidectomy using multidisciplinary research techniques. The practical significance of the dissertation consists in the justification of the advantages of apparatus hemorrhoidectomy with mechanical suture in terms of postoperative pain, complication rate, and economic efficiency, which allows recommending this method for wide application in practical surgery.

Hemorrhoids are one of the most common diseases of humankind. Its prevalence amounts to 130–145 cases per 1,000 adult population. The frequency of hemorrhoids in the structure of proctological diseases ranges from 34% to 41%. Despite the fact that in European and American countries minimally invasive methods of hemorrhoid treatment have been actively developed and applied, in Russia hemorrhoidectomy remains the leading method. According to domestic authors, 75–79% of patients hospitalized for hemorrhoid undergo hemorrhoidectomy [21].

Surgical methods of hemorrhoid treatment are constantly undergoing evolution. Among new methods are removal of hemorrhoidal nodes using the radiogenic device «Surgitron», ultrasonic (harmonic) scalpel, the «Liga Sure» device, and the Longo procedure. However, the use of these techniques has not gained wide spread in our country, and to date the most frequently applied method for hemorrhoids remains the Milligan-Morgan operation. This is explained by the high cost of equipment, on the one hand, and the absence of substantial advantages in treatment outcomes compared with traditional radical hemorrhoidectomy, on the other.

The most in-depth and comprehensive investigation of modern methods of surgical hemorrhoid treatment was conducted by Kalanov R.G. [30] and Blagodarny L.I.A. [13]. Good results were obtained in 99% of patients. However, in 23% of patients who underwent closed hemorrhoidectomy, pain syndrome was observed in the early postoperative period. The minimum number of complications was noted in operations using mechanical suture.

From an economic standpoint, hemorrhoidectomy with mechanical suture also surpasses other methods of hemorrhoidectomy. Hospital treatment costs for closed hemorrhoidectomy with catgut suture amount to 1,341.6 rubles; for hemorrhoidectomy using the UDO-38 device — 1,221.4 rubles; for hemorrhoidectomy using the TLV-30 device — 4,425 rubles. Patient costs for the apparatus for the Longo operation amount to 24,000 rubles.

Since 1988, in City Clinical Hospital No. 24, closed hemorrhoidectomy with mechanical suture using the Pediatric Organs Suturer-38 (UDO-38) has been employed. The operation was developed and introduced into clinical practice by D.M.N. Aleksandrov V.B.

Its positive qualities and minimal number of complications constantly convince the proctologists of the hospital of the correctness of choosing precisely this method of surgical treatment of hemorrhoids.

Given the prevalence of hemorrhoids, determining the advantages of one or another surgical method for this disease remains an actual and practically very important task to this day. Reducing the duration of inpatient and outpatient treatment for hemorrhoids, which typically affect people of the most productive age, and employing the most economically justified operative method constitute an important medical and socio-economic problem.

The aim of this study is a comparative evaluation of the results of treatment of chronic hemorrhoids using mechanical suture (UDO-38 device) and closed standard hemorrhoidectomy.

To achieve the aim of the study, the following tasks were set:

1. to conduct an analysis of clinical results of hemorrhoidectomy using mechanical suture and closed standard hemorrhoidectomy;

2. to study the severity and dynamics of pain syndrome, urinary disturbances, and quality of hemostasis;

3. to conduct a comparative evaluation of the degree of inflammatory process on the anal mucosal according to the cytological picture;

4. to investigate the dynamics of the microbial «landscape» depending on the type of surgical intervention;

5. to identify differences in the postoperative state of the internal anal sphincter using ultrasonic investigation;

6. to evaluate long-term treatment outcomes;

7. to compare the economic efficiency of hemorrhoidectomy using the UDO-38 device and closed standard hemorrhoidectomy.

The material for this study consisted of the treatment outcomes of 116 patients operated for hemorrhoids at City Clinical Hospital No. 24 of the Department of Healthcare of Moscow in 2002–2004. Treatment outcomes were traced for up to 3 years. Apparatus hemorrhoidectomy was performed in 62 patients, and surgery using traditional suture material in 54 patients.

Scientific novelty

For the first time, a comparative analysis of immediate and long-term results of two variants of closed hemorrhoidectomy — using the UDO-38 device and hemorrhoidectomy using standard suture material — was conducted, based on clinical, cytological, microbiological, and first-ever developed transperineal-transvaginal ultrasonic investigation of the anal canal, enabling assessment of the degree of severity of hemorrhoidal nodes and the functional state of the sphincter apparatus.

Thesis statements for defense:

1. The technique of closed hemorrhoidectomy using mechanical suture leads to a reliably greater number of favorable treatment outcomes.

2. Closed apparatus hemorrhoidectomy is accompanied by a minimal number of postoperative complications.

3. The economic efficiency of closed hemorrhoidectomy using the UDO-38 device is reliably higher than that of closed standard hemorrhoidectomy.

Practical significance

For the first time, a comparative evaluation of the economic efficiency of two methods of hemorrhoidectomy was conducted.

It was established that apparatus hemorrhoidectomy is simple to perform, is radical, is accompanied by a reliably minimal number of postoperative complications, and is economically more efficient.

The analysis of immediate and long-term surgical outcomes justifies the assertion that closed hemorrhoidectomy using mechanical suture allows combined operations on the anal canal to be performed without risk of complications.

The advantages of apparatus hemorrhoidectomy allow it to be recommended for wide application in practical surgery.

The author expresses sincere gratitude to his scientific supervisor — head of the Department of Surgery of the Vladimirsky Moscow Regional Research and Clinical Institute (MONIKI), head of the abdominal surgery department of MONIKI, Doctor of Medical Sciences, Professor A.I. LOBAKOV; his teacher — chief physician of City Clinical Hospital No. 24 of the Department of Healthcare of Moscow, Chief Proctologist of Moscow, Doctor of Medical Sciences V.B. ALEKSANDROV; Deputy Chief Physician of GKB No. 24 for medical work O.Yu. RAKHIMOVA; Deputy Chief Physician of GKB No. 24 for surgery Yu.A. VINOGRADOV; head of the Clinical-Diagnostic Department E.V. ANTIPOVA; head of Surgical Department No. 2, Candidate of Medical Sciences A.B. TUMANOV; economist of GKB No. 24 A.E. KANEVSKAYA; cytologist of the N.N. Burdenko City Clinical Hospital, Candidate of Medical Sciences N.Yu. KOTLYAR; head of the bacteriological laboratory of GKB No. 24 L.I. SHIRMAN; staff members of the ultrasound investigation department of GKB No. 24 O.R. ERMAKOVA and S.M. KANDELAKI; senior research fellow of the thoracic surgery department of MONIKI, Candidate of Medical Sciences M.I. PRISHCHEPO, for constant help and support during the completion of the doctoral work. The author thanks the entire collective of City Clinical Hospital No. 24, especially the staff of the consultative-diagnostic department, Surgical Department No. 2, and the department of general and urgent proctology for their friendly participation and assistance.