To the Editor:
In the published report of Gravié et al,1 comparing the outcome of stapled hemorrhoidopexy with that of the Milligan-Morgan technique, stapled hemorrhoidopexy is recommended as the preferred technique for hemorrhoidal prolapse. In our opinion, this conclusion is at least questionable. A meta-analysis of 9 studies showed a worse rate of recurrent prolapse after hemorrhoidopexy, concluding that hemorrhoidectomy remains the “gold standard” procedure.2 A multicenter study has shown that hemorrhoidopexy provided similar control of symptoms than hemorrhoidectomy in patients with third-degree hemorrhoids.3 Other studies demonstrated that hemorrhoidopexy was more successful in treating third-degree hemorrhoids than in fourth-degree hemorrhoids at the 1-year follow-up.4 The effectiveness of the hemorrhoidopexy as a definitive cure in patients with fourth-degree hemorrhoids is controversial. Of the 7 randomized trials published in the literature in which patients with fourth-degree hemorrhoids were included,5–11 in 3 of them8–10 the results obtained in the resolution of one or various hemorrhoidal symptoms after the stapled technique were worse than after hemorrhoidectomy. Moreover, defecation disturbances, such as urgency, were observed. In this respect, it should be noted that, in the consensus position paper of stapled hemorrhoidopexy, it was stated that these symptoms should be included in the informed consent.12 Taking into account the significant variation in the distance of the staple line above the dentate line, it appears that the technique is not as easily reproducible as it is claimed in the paper or that results are not dependent on whether or not the technique has been standardized. This is clearly in contrast with the consensus document12 and the original description of Antonio Longo.13 Therefore, it seems that the appropriate conclusion would have been that hemorrhoidopexy is an adequate technique for the treatment of third-degree hemorrhoids. Finally, the consensus report cited in the reference list as “in press” was in fact published in 2003.
Hector Ortiz, MD, PhD
Universidad Publica de Navarra
Navarra, Spain
REFERENCES
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