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Long-term Evaluation of Stapled Hemorrhoidopexy (by Longo):
A 15-year Follow-Up Study
The stapled hemorrhoidopexy by Longo is one of the most frequently used surgical procedures for the treatment of advanced hemorrhoidal disease. Compared to conventional surgical procedures, shorter times for surgery, hospitalization, incapacity for work, convalescence, as well as lower postoperative pain and higher patient satisfaction at similar complication rates have been demonstrated . While initial studies suggested that the rate of recurrence in stapled hemorrhoidopexy is increased compared to conventional methods, there are no long-term results with a follow-up period of more than 10 years yet.
The aim of this study is to obtain first long-term results on the outcome of the stapled hemorrhoidopexy with a mean observation period of more than 15 years. In addition to symptoms, recurrences, follow-up treatments and complications the influence of age and gender of the operated patients should also be considered in a first analysis.
A telephone survey was carried out on patients who participated in the follow-up study at the “Kliniken Essen-Mitte” after having been operated by a stapled hemorrhoidopexy in the years 1999 - 2003. An initial long-term study of this group of patients was performed by Hinrichs and Ommer in 2007 .
With the aid of a survey questionnaire the survey was partially standardized, so that besides the directly surveyed aspects, information could also be included qualitatively in the sense of an explorative approach. In addition to information about haemorrhoidal symptoms in the previous postoperative course, new treatments, complications and satisfaction, personal data on age, gender and time of the operation were also recorded.
A descriptive analysis of the data was followed by a multivariate analysis on the influence of age and gender on the outcome of the operation in the statistical analysis.
Survey, data entry and analysis were piloted at the beginning of the survey in the form of a pre-test. After a first pretest evaluation the study design was adapted, so that further survey and analysis could be optimized.
Of the 233 patients participating in the follow-up study (total number of patients operated: n = 259), 117 patients were interviewed who underwent treatment for hemorrhoidal disease with a stapled hemorrhoidopexy before an average of 15.23 years.
52.86% (61/116) of these respondents reported no longer experiencing hemorrhoidal symptoms since the surgery. In 22.41% (26/116) complaints occurred after more than 10, in 1.72% (2/116) after five to ten, in 6.03% (7/116) after three to five and in 2.59% (3/116) after one to three years. 10.34% (12/116) of the interviewed patients said that they had never been without symptoms before and 4.31% (5/116) within one year. Of these patients who reported being not completely symptom-free (n = 55), 83.33% (40/48) experienced a reduction in hemorrhoidal symptoms until the time of this survey.
A further treatment of hemorrhoidal disease in the previous postoperative period was carried out in a total of 21.43% (24/112) of the surveyed patients: in 15.18% (17/112) surgery was necessary due to a recurrence; 16.07% (18/112) received sclerotherapy and 20.72% (20/112) ointment or suppository treatment. 15.45% (17/110) of the patients surveyed reported that a stool-holding weakness first occurred after the operation. One patient (0.9%) said that this symptom had occurred temporarily after surgery. Another 17.95% (21/75) - 28.0% (21/75) complained of a new onset fecal urgency without fecal incontinence in the postoperative course. 9.38% (9/96) reported that a defecation disorder had occurred after surgery for the first time.
The analysis of the influence of age and gender on the outcome of surgery showed that female patients were less likely to experience complete freedom from symptoms from the operation than men. In addition, with increasing age, more patients reported having experienced complete symptom-free surgery until the time of follow-up. Also, postoperative bowel weakness persisted a bit more frequently in the operated women, as well as with increasing age. In the multivariate analysis, however, neither the variables "age" nor "gender" were significant in terms of obtaining complete freedom from symptoms.
The question of satisfaction with the operation was answered by 81.58% (93/114) of patients as "very satisfied" or "satisfied", 7.89% (9/114) as "moderately satisfied" and 10.53% (12/114) as "not at all satisfied". In the group of "not at all satisfied" patients, the proportion of operated female patients was increased - 17.95% (7/39) of the operated women indicated that they were "not satisfied" compared to 6.67% (5/75) of the operated men.
With a complete cure of hemorrhoidal disease at 52.86% (61/116) and sustained symptom relief at a further 22.41% (26/116) a majority of operated patients benefited significantly from the procedure. Nevertheless, the reported recurrence rate and complication rate for stool-holding disorders and fecal urgency 15.45% (17/110) and 17.95% (21/117) - 28.0% (21/75) appear to be high in the long-term course.
Previous studies with a shorter postoperative observation period described significantly lower complication rates and a higher rate of surgical success [3-5]. In a multi-center evaluation in 2001 by Herold et. al. the complication rate was 9.8% . However, at the time of this study, neither conventional nor stapled haemorrhoidopexy studies have long-term studies comparable to those observed in this study.
Considering the present results it seems possible that female patients benefit more from the operation than male patients, but the descriptive statistics do not provide a causal explanation. In the latest guidelines  a therapy of the hemorrhoidal disease is recommended depending on the clinical examination findings and the symptoms of the complaint. Even though an individual therapeutic approach is required, no specific recommendations are made for possible influencing factors to be considered.
Both in terms of possible factors influencing the surgical outcome and the long-term comparison of various surgical procedures, further research in favor of an individualized and patient-oriented care appears desirable.
This study revealed a high complication and recurrence rate in the postoperative course of stapled haemorrhoidopexy by Longo. In consideration of the available data, a reserved indication still appears to be sensible.