J. Coloproctol. (Rio J.) vol.37 número4

w w w . j c o l . o r g . b r

Journal

of

Coloproctology

Original

Article

Retained

or

expelled

staples

after

transanal

stapled

surgery:

this

is

the

problem!

Alessandro

Sturiale

,

Jacopo

Martellucci

,

Gabriele

Naldini

b_{CareggiUniversityHospital,EmergencyandMini-invasiveSurgery,Florence,Italy}

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received31March2017 Accepted4June2017 Availableonline13July2017

Keywords:

Stapledtransanalresection Haemorrhoids

STARR ODS Staples

a

b

s

t

r

a

c

t

Studyobjective:Theaimistoassessthepresenceandpersistenceoftheagraphesatthelevel ofstaplelineaftertransanalstapledsurgery.

Methods:FromApriltoDecember2016one-hundred-thirteenpatientswithvariable follow-up(6months–10years)wererandomlyselectedamongallthepatientsundergonetransanal stapledsurgeryforhaemorrhoidaldiseaseorfunctionaldisorderssuchasobstructed defeca-tionsyndrome.Only87patientsagreedtoparticipatethisstudy.Allthepatientsunderwent digitalexploration,anoscopyand360◦_{tridimensionaltransanalultrasound.}

Mainresults:Differenttypesofstapledtransanalsurgicalprocedureswereperformed:48 transanalrectalresectionwithhighvolumedevice,24stapledhaemorrhoidopexy,8Double StapledHaemorrhoidopexy,7Transtarr.In41.4%thestaplelinewasnotidentifiedwith digitalexaminationoranoscopyand17.2%ofpatientshavesomestaplespartiallyexpelled insidethelumen.360◦_{tridimensionaltransanalultrasoundshowedacompletestapleline}

attheano-rectaljunctionwhichappearsasaninterruptedhyperechoiccircularlayer.

Conclusion:Thestaplesafterstapledtransanalsurgeryremainatthelevelofthestapleline independentlyfromthedeviceusedbythesurgeonleadingtothenecessityofasharedand adequatelanguage,infacttheshedstaplesneedtobeconsideredasexpelledinsteadof retained.

©2017PublishedbyElsevierEditoraLtda.onbehalfofSociedadeBrasileirade Coloproctologia.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Grampos

retidos

ou

expelidos

em

seguida

à

cirurgia

transanal

com

grampeador:

eis

aí

o

problema!

Palavras-chave:

Ressecc¸ãotransanalcom grampeador

Hemorroidas

r

e

s

u

m

o

Objetivodoestudo:Avaliarapresenc¸aepersistênciadosagrafesaoníveldalinhadeaplicac¸ão dosgrampos,emseguidaàcirurgiatransanalcomgrampeador.

Métodos:Deabrilatédezembrode2016,113pacientescomseguimentosvariáveis(6 meses-10anos)foramaleatoriamenteselecionadosentretodosospacientestratadoscomcirurgia

∗ _{Correspondingauthor.}

E-mail:alexstur@yahoo.it(A.Sturiale).

http://dx.doi.org/10.1016/j.jcol.2017.06.005

STARR ODS Grampos

transanal comgramposparatratamentodehemorroidas oudetranstornosfuncionais, por exemplo, síndromede evacuac¸ãoobstruída. Apenas 87pacientes concordaramem participardoestudo.Todosospacientespassaramporexplorac¸ãodigital,anoscopiae ultra-ssonografiatransanaltridimensionalde360◦_.

Resultados principais: Foram realizados diferentes tipos de procedimentos cirúrgicos transanaiscomgrampeador:48ressecc¸õesretaistransanaiscomusodegrampeadorde grandevolume,24hemorroidopexiascomgrampeador,8hemorroidopexiascomgrampos duplose7procedimentoscomgrampeadorTranstar.Em41,4%dostratamentos,nãofoi pos-sívelidentificaralinhadegrampeamentocomexamedigitaloucomanoscopia,eem17,2% dospacientesalgunsgramposforamexpelidosparaolúmen.Aultrassonografiatransanal tridimensionalde360◦_{revelouumalinhadegrampeamentocompletonajunc¸ãoanorretal,}

assumindooaspectodeumacamadacircularhiperecoicainterrompida.

Conclusão: Emseguidaàcirurgiatransanalcomgrampeamento,osgrampospermanecem aoníveldalinhadegrampeamento,independentementedotipodegrampeadorusadopelo cirurgião,oquetornanecessáriaumalinguagemcompartilhadaeadequada;defato,os grampossoltosdevemserconsideradoscomoexpelidos,emlugarderetidos.

©2017PublicadoporElsevierEditoraLtda.emnomedeSociedadeBrasileirade Coloproctologia.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Mechanicalstaplerisoneofthegreatestsurgicalinnovation ofthelastcentury.Itallowstoperformquickandeasy pro-ceduresresultingsafeand effective.Thepioneerofstapler procedureswithhisprototypeweighted3.6kgwasHúmerHült alsoknownasthe“fatherofsurgicalstapling” in1908.The technologicaldevelopmentpassedthroughseveralcountries andlotsofdifferentdevices,firstlyusedforbloodvesselsand thenappliedtotheboweltoo.1–5 _{Fromtheinitialapplication}

intheabdominalopensurgerythetechnologyfollowedthe trendofcontinuoussurgical improvementmaintainingthe samestandardlevelsalsointhenewlaparoscopicapproach and it always leaded to new devices. Stapled surgery for thetreatmentofhaemorrhoidalprolapse, theso-called sta-pledhaemorrhoidopexy(SH),wasfirstlydescribedbyLongo in 1998 as a less painful alternative to the conventional haemorroidectomy.6 _{Sincethatmoment,therewere lots of}

technologicalchanges,someofthemareclearlyvisiblesuch astheshapeand ergonomicswhileothers areless evident butfundamentaltoimprovedeviceperformance.Acommon elementtoallthedifferenttypeofstapleristheuseof non-magnetic,inert metalstaples which may guaranteea long lasting.Lotsofstudywereperformedtoassessmetals prop-ertiesandtheyconcludethatthebestchoiceistitaniumor titaniumalloy7_{ratherthanstainlesssteelwhichwasusedat}

first.Althoughitmayseemfairlyclearthefateofthestaples afterbowel anastomosis, the surgeons are oftennot well-informedaboutthisand theyuseinaccuratetermscausing lotofconfusionabouttheprocedure,itseffectsandthe possi-blepostoperativecomplications.Theaimofthepresentstudy istoassessthepresenceandpersistenceoftheagraphesat thelevelofstaplelineaftertransanalstapledsurgery.

Methods

From April 2016 to December 2016 one-hundred-thirteen patientswithvariable follow-up(range:6months–10years)

were randomly selected amongall the patients undergone transanalstapledsurgeryforhaemorrhoidaldiseaseor func-tional disorders such as obstructed defecation syndrome (ODS). They were retrospectively collected through clinical records and then telephone called for an outpatient eval-uation. Only 87 patients agreed to undergo this further follow-upnotscheduled.Allthepatientsunderwentphysical examinationthroughdigitalexploration,anoscopyand360◦ tridimensionaltransanalultrasound.Theevaluationwas per-formedbytwoexperiencedsurgeonsspecializedincolorectal andproctologicalsurgery.

Results

Fig.1–(A,B)Anoscopy:partiallyexpelledstaplesatthelevelofthestapledlinewithoutanysignofinflammation.

Fig.2–360◦_{tridimensionaltransanalultrasound:yellowarrowsindicatethestapleline.(A)2Dvisualization;(B,C)3D}

Discussion

Starting from the beginning of the last century the tech-nology simplified and made it easier some surgical steps. A central role in this field was played by the mechanical staplerwhichwere usedtoperformblood vesselsorbowel anastomosis.1,3 _{In1998Longo describedthe useofa}

circu-larstaplertotreatthehaemorrhoidalprolapse6_thenapplied

forobstructeddefecationsyndrometoo.Afterthisexperience stapledhaemorrhoidopexyspreadworldwideandthesaleof thedevices widelyincreased.Thegrowingsurgical innova-tion and theneed toimprove the outcome haveleaded to the introduction ofthe double stapled procedure toresect alltheprolapsedtissuewhichotherwisewouldnotenterin asingledevicecasing.8_{However,incaseofmultiplesuture}

line there are some weak and fixed points atthe level of thecrossingsutures.Anotherconsequenceofmultiple rec-talresectionisthattherectalprolapseisresectedinpieces anditisnotsymmetrical.Whereby,newdedicatedhigh vol-umedeviceswererecentlyintroducedtoallowacylindrical rectal resection.9,10 _{In all ofthese different phases of}

sta-pledprocedureevolutionforthetreatmentofhaemorrhoidal diseaseandODStoo,thecommondenominatorwasthe fash-ioningofrecto-rectalanastomosisusingtitaniumortitanium alloy agraphes.This typeof staples allowsthe patients to undergowhateverradiologicalimagingsuchasCTscanorMRI becausetheyarenonmagneticandinertandtheyguarantee toremaininthesamesite. Althoughit maybeanobvious andsimpleconcept ofthestaplers use, it isnot.In fact, a recent paper reported a surveycarried out among 16 sur-geonsexperiencedinSH.Theauthors askedthemthe fate ofthestaples.Ten(62.5%)ofthemanswered thattheywill beshedwithin3months,3answeredthatthestapleswillbe retainedinsidepermanently,2answered thatonlysomeof themareshedand1expressedignoranceaboutthistopic.11

Thisisaclarifyingstudyregardingtheignoranceand confu-sionaboutthefateofthestaplesusedtotreathaemorrhoidal prolapseorODS-relatedalteredanatomy.Italsorevealedan importantissue, approximately75% ofpatients undergoing stapledsurgerywishestoknowmoreabout thetechnology usedto treattheir disease.11 _{Besides, the presenceof}

par-tiallyexpelledstaplesinsidetherectallumenwhicharenot correctlyintegratedinsidethestaplelineandcoveredbythe mucosallayermaybethecause ofsomebothersome post-operativesymptoms.Thespectrumofthesesymptomscan varyfromsporadicbleedingduetothepresenceofgranuloma abovethepartiallyexpelledstaplestochronicpain, inflamma-torypolyporevenproctitis.12–15_{Onlyfewcasesarereported}

aboutpeniletrauma,condomruptureoranalpainduringanal intercourseafterstapledhaemorroidopexy.16–19

Inthe presentstudy the associationofdigital examina-tion,anoscopyand360◦_{tridimensionaltransanalultrasound} confirmedthatthestaplesaftertransanalstapledprocedure remaininsidetherectal wallatthe levelofthe anastomo-sis and that sometimes only few of them are completely orpartially expelled.Moreover,the long lastingofthe sta-plesresultedtobeindependentfromthetypeofthedevice chosenbythe surgeon (PPH, ContourCCS-30, TST STARR+ 36).

Theseresultsareinkeepingwithotherpublishedpapers aboutstapledproceduresindifferentsurgicalfieldssuchas abdominalsurgery.Nevertheless,nowadaysthepersistenceof thestaplesinsidetheabdomenafterbowelsurgeryorinside the thorax afterlung resection is notso debated. Two are thepossiblereasons.Firstly,staplerinabdominalorthoracic surgeryisroutinelyusedandtheyrepresentonlyastepofthe wholesurgicalprocedure.Theuseofthemechanicaldeviceis notnecessaryanddependsonthesituationandanatomical condition,infact,atpresent,ithasbeenalsodemonstrated that stapled anastomosis iscomparable to the hand-sewn withoutanysuperiorityofoneovertheother.20_Secondly,in

upperGI,colorectal21_andbariatric22_{surgerythepresenceand}

persistenceofthestaplesattheleveloftheanastomosisis consideredasamarkertoeasilyidentifyitinfluoroscopyor throughCTscananditisusedinthepost-operativeevaluation ofdehiscenceorleak.Ontheotherhand,thechooseofstaple procedureforhaemorrhoidaldiseaseorODSrepresentsthe wholesurgicaltreatment.Animportantkeypointisthatthe staplelineisveryclosetotheexternalanalverge,around4cm, sothatthepatientsthemselvesmayfeelit,differentlyfrom abdominalorthoracicsurgeryinwhichthepatients,evenif theyknow,theyhavenotarealperceptionandawarenessof thestaples.Anotherissue,whichisnotsodebated,isrelated to the anal intercoursesafter this typeofsurgery because boththepatientand/orhis/herpartnersmayexperiencepain, stiffnessorpeniletrauma.Thisconditionrevealedtohavean importantimpactonthequalityoflife,sexualhabitsand per-sonalandsocialsexualityonhomo/bisexualandheterosexual population. However,so farthe literaturelacksacomplete and exhaustivestudy analysingthe impactofthe different proctologicsurgicalproceduresonanalintercourses.

Thisbackgroundclearlyexplainswhythesurgeonsneed todeepenstaplestopic,especiallyforthetreatmentofbenign proctologicdiseaseandalsoclarifywhyitwasnotsodeeply analyzedbefore.Thepresentpaperfirstanalysestherealfate oftheagraphesinpatientswithdifferentfollow-up,upto10 years,aftertransanalstapledsurgery. Theprocedureswere performedwithdifferentdevicestotreathaemorrhoidal dis-ease or functional disorders suchas obstructeddefecation syndrome.

Therefore,itistimetomoveonandtouseacorrectand sharedmedicallanguage. Itisnotmoreadequate tospeak aboutretainedstaplesbecauseallthestaplesormostofthem are usually retained,whereby it is moreaccurateto speak aboutexpelledstaples.Theexpelledstaplesarethosewhich are partiallyor completely shed from the staple line. This may beaconsequenceofanimperfectfire ofthe machine andforthisreasonthecompaniesproducingstaplingdevices continuouslyimprovethefeaturesofthestaplers.Infact, tech-nologicalinnovationleadstotheintroductionandapplication ofnewpatentedchanges,suchaspermanentparallelcontrol system,allowingagreaterstabilityandbalanceduringthefire. Neverthelesssomestaplesaresometimespartiallyexpelled andtheycanremainasymptomaticorarethecauseof postop-erativehassles.Thisconcepthasalsoimportantimplications inthefieldofforensicmedicineregardingcompensationof damagesaftertransanalstapledsurgery.

ofthechosenprocedurewhichneedstobeclearlyreported insidetheinformedconsent.Itmustbeperformedusing pre-ciseand specific terms that the canbe understood bythe patientsand atthe sametime didnotgenerate misunder-standingintheassessmentdonebyforensicdoctors,lawyers andjudges.

Conclusion

Thestaplesafterstapledtransanalsurgeryremainatthelevel ofthestaplelineindependentlyfrom thedeviceused.This conceptleadstothenecessityofacorrectlanguagewhereby theshedstaplesneedtobecalledexpelledinsteadofretained. Besides,theknowledgeofthedeviceanditsrelatedfeatures andpossiblepostoperativeconsequencesisatthebaseofa correctuseofthestapleranditisessentialforanadequate managementofpostoperativecomplicationsortroublesome symptoms.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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