Transanal hemorrhoidal dearterialization with mucopexy versus Ferguson hemorrhoidectomy for prolapsed internal hemorrhoids: A multicenter prospective study
Mahir Gachabayov*1, George Angelos2, Guy Orangio3, Herand Abcarian4, Roberto Bergamaschi1
1Surgery, Westchester Medical Center, Valhalla, NY; 2Stony Brook University, Stony Brook, NY; 3University of Louisiana, New Orleans, LA; 4University of Illinois in Chicago, Chicago, IL
Background: Transanal hemorrhoidal dearterialization (THD) with mucopexy is associated with better short-term postoperative outcomes as compared with excisional hemorrhoidectomy as previously reported. However, there is uncertainty regarding the durability of the therapeutic effect of THD with mucopexy compared to Ferguson hemorrhoidectomy in terms of recurrence rates. This study aimed to compare the two procedures in patients with internal hemorrhoids in terms of clinical outcomes, patient-reported outcomes, and rates of recurrence.
Methods: This was a multicenter prospective study registered at clinicaltrials.gov (NCT03245086). A non-randomized design was chosen in order to control for learning curve bias. Participating surgeons performed the study intervention reflecting their custom of practice enrolling 10 patients each. Surgeons had to be board-certified in colorectal surgery and their unedited videos were reviewed by an expert prior to participation. Patients with prolapsed internal hemorrhoids in at least 3 columns on physical examination were eligible. The primary endpoint was recurrence rates at a minimum of 1 year, defined as prolapsing internal hemorrhoids at physical examination. Secondary endpoints included postoperative pain scores and rates of urinary retention, constipation, dysuria, pruritis ani, anal pain, anal stenosis, unhealed wound, anal fissure, fecal urgency, and incontinence. Patient-reported outcomes were evaluated using Pain Scale and Brief Pain Inventory, Fecal Incontinence Quality Of Life (FIQOL), Cleveland Clinic Incontinence, Constipation, and Short-Form 12 (SF-12) scores.
Results: Twenty colorectal surgeons from 15 US sites enrolled 197 patients. THD with mucopexy and Ferguson hemorrhoidectomy arms were comparable for age (p=0.774), gender (p=0.512), race (p=0.334), body mass index (p=0.698), time from symptoms onset (p=0.662), Pain Scale (p=0.214), Brief Pain Inventory, FIQOL (p=0.847), Cleveland Clinic Incontinence (p=0.937), Constipation (p=0.301), and SF-12 (p=0.563) scores. Postoperatively, THD patients had lower Pain Scale scores at POD1 (6.2 vs. 8.3, p=0.047), POD7 (4.5 vs. 7.7, p=0.021), POD14 (2.8 vs. 5.3, p<0.001) as well as pain medication rate at POD14 (23% vs 58%, p<0.001). ER visit rates did not differ (2% vs. 5%, p=0.397). The rate of postoperative complication did not differ at POD14 (7% vs. 9%, p=0.106), but was lower in THD patients at 3 months (2.5% vs. 6%, p=0.048). Patient satisfaction rate was higher after THD at POD14 (76.4% vs 52.5%, p=0.031) and 3 months (95.1% vs 63.3%, p=0.029), but did not differ at 6 months (91.7% vs. 88.2%, p=0.228) and 1 year (94.2% vs. 87.9%, p=0.836). Median follow-up was 3.1 (1.0 – 5.5) years. Recurrence rates did not differ between the study arms (5.9% vs. 2.4%, p=0.253).
Conclusion: THD with mucopexy was associated with improved patient-reported outcomes and quality of life as compared to Ferguson hemorrhoidectomy with non-significantly different recurrence rates.
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