AN OBSERVATIONAL COMPARATIVE STUDY OF STAPLER HEMORRHOIDOPEXY AND THE MILLIGAN MORGAN OPEN HEMORRHOIDECTOMY IN TERTIARY CARE CENTER OF CENTRAL INDIA

1. Resident, General surgery, Sri Aurobindo Medical College & Postgraduate Institute, Indore, Madhya Pradesh, India. 2. Associate Professor, General surgery, Sri Aurobindo Medical College & Postgraduate Institute, Indore, Madhya Pradesh, India. 3. Senior Resident, GI Surgery, BMHRC Bhopal, Madhya Pradesh, India. 4. Assistant Professor, General surgery, Sri Aurobindo Medical College & Postgraduate Institute, Indore, Madhya Pradesh, India. 5. Senior Resident, General surgery, GMC, Vidisha, Madhya Pradesh, India. 6. Resident, General surgery, Sri Aurobindo Medical College & Postgraduate Institute, Indore, Madhya Pradesh, India. 7. Professor, General surgery, Sri Aurobindo Medical College & Postgraduate Institute, Indore, Madhya Pradesh, India. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 01 September 2020 Final Accepted: 05 October 2020 Published: November 2020

.05 ± 1.84 with the mean difference being 2 days (P<0.001). The duration of recovery was significantly faster in stapler group with the mean hospital stay being 7.55 as compared to the open group 12.45 with mean difference being 5 days(P<0.001). Postoperative bleeding was found in both the groups which eventually subsided completely in stapler group on POD -7 and only 3 [7.5%]. Patients had bleeding on POD -7 in the open group. (P < 0.001). The findings were statistically significant as suggested by P-Value. Urinary Retention was found in both groups i.e. 5% and 7.5% in stapler and open group respectively. (P= 0.632).

Conclusion:
The results of this study concluded that Stapler hemorrhoidopexy had lesser operating time, lower duration of hospital stays, and quicker recovery with less postoperative pain & bleeding as compared to Open hemorrhoidectomy. Hence it was concluded that stapler hemorrhoidopexy is a better option as compared to open hemorrhoidectomyfor grade II. grade III, & a few selected cases of grade IV hemorrhoids. patient's stapler procedure was choice in grade II haemorrhoids.

…………………………………………………………………………………………………….... Introduction:-
Hemorrhoids, also called piles, are vascular structures in the analcanal. (1,2) In their normal state, they are cushions that help with stool control. (3) They become a disease when swollen or inflamed; the unqualified term "hemorrhoid" is often used to refer to the disease. (4) The signs and symptoms of hemorrhoids depend on the type present. (5) Internal hemorrhoids often result in painless, bright red rectal bleeding when defecating. (5)(6) External hemorrhoids often result in pain and swelling in the area of the anus. (5) If bleeding occurs it is usually darker. (5) Approximately 50% to 66% of people have problems with hemorrhoids at some point in their lives. (6,8) Males and females are both affected with about equal frequency. (8) Hemorrhoids affect people most often between 45 and 65 years of age (9). It is more common among the wealthy. Outcomes are usually good. (6)(7)(8) They are often assigned blame for purities ani, analfissures, condylomataacuminata, fistula in ano and incontinence. Treatment for hemorrhoids is only needed if they are truly symptomatic. the disease. The present study was designed to compare stapler hemorrhoidopexy and the Milligan Morgan open hemorrhoidectomy on a set of predetermined parameters.

Aim and Objectives:-
Aim: The purpose of this study is to compare between open Hemorrhoidectomy vs stapler hemorrhoidopexy outcome in terms of post operative complications and quality of life in a tertiary health centre.

Objectives:-
The purpose of this study was to compare the outcome of stapler hemorrhoidopexy (SH group) performed using a circular stapler with that of the Milligan Patients were subjected to clinical examination and routine laboratory investigations preoperatively. All patients were operated on on an in-patient basis. The patient's hospital stay for analysis was calculated starting from the day of surgery. Preoperatively patients were kept nil per oral overnight prior to surgery. One dose of antibiotics was given at the time of anesthesia for surgery. All operations were performed in the lithotomy position under spinal anesthesia. Patients were reexamined under anesthesia to confirm the grade of hemorrhoids and to rule out associated anal pathologies like anal fissure and fistula in ano. Patients were operated on by prefixed operative procedure as per group 1 / 2. The patient was started on a soft oral diet within 4 hours postoperatively. The dressing is removed on the morning after surgery and a local external visual examination is done. Postoperative pain was managed according to the guidelines of the French anesthesia society. The pain was assessed using a visual analog scale (vas) where 0 represented no pain and 100 represented the worst pain ever. The pain score was recorded on a postoperative day 1 with the effect of analgesia, and postoperative day 3without analgesia and at the end of the first week without analgesia. The aim was to keep the vas score below 50 with adequate analgesia. In addition to analgesics, patients have advised antibiotics and syrup lactulose 20 ml at bedtime for two weeks. Patients undergoing open hemorrhoidectomy were also advised sitz bath twice daily for two weeks. Patients were discharged when pain control and home circumstances permitted. An outpatient appointment for review was given one week after surgery. Patients were advised to report immediately in cases of emergency. On follow up patients were asked to rate the control of their symptoms. degree of continence to flatus and feces, duration to return to normal activities, and any other problems they had. A physical examination was also carried out at each follow-up. The outcome measures were postoperative pain, postoperative bleeding, analgesic requirement, operative time, hospital stay, time to return to normal activity, and complications. Patient data collection sheet was used for data collection.

Statistical Methods:
Both descriptive and inferential statistics were used to identify the feature and characteristics of the data. Continuous variable was expressed as mean + / -SD or range. The non -continuous variable was expressed as the number of occurrence and percentage. Chi-square test was used to identify the association between variables. Microsoft Excel was used to prepare the master charts. A P-value less than 0.05 was considered as significant. Student T-test was carried out for continuous parameters if data found to be normal.           Urinary Retention in the stapler group was present in 2 cases whereas in the open group 3 patients went into urinary retention. P-value = 0.632 which is Not significant.

Discussion:-
Hemorrhoidectomy is the accepted method for the treatment of large symptomatic piles. Conventional hemorrhoidectomy is an effective operation that has withstood the test of time however, the problem of postoperative pain has never been satisfactorily addressed. The postoperative pain related to Conventional hemorrhoidectomy is well known. Patients will frequently avoid definitive treatment of their disease for many years so as to avoid this very problem. Also, the high postoperative morbidity and long recovery have prompted the need for an alternative procedure. Several techniques, including diathermy haemorrhoidectomy, dilatation with banding, and cryo-haemorrhoidectomy have been tried. Stapler hemorrhoidopexy offers a significantly less painful alternative that provides patients definitive treatment of their disease in a single sitting. Stapler hemorrhoidopexy was introduced in 1995 by Longo. A novel technique in dealing with the management of hemorrhoidal disease, it has emerged as an alternative to open hemorrhoidectomy, long considered the "gold standard". It treats the mucosal prolapse, with concurrent disruption of the blood supply to the hemorrhoidal tissue. The technique has been standardized and the indications, contraindications, and operative technique have been defined. Several randomized trials have shown the efficacy and safety of the procedure. There has been some concern and reluctance in accepting Stapler hemorrhoidopexy as few serious complications have been reported. These include persistent postoperative pain, fecal urgency, recto-vaginal fistula, rectal obstruction, perforation peritonitis, and pelvic sepsis. These have all been seen by most investigators in the early part of the learning curve. Numerous controlled studies have already demonstrated that this technique is associated with less postoperative pain and a quicker recovery. Right from the earliest study, there is a high patient satisfaction rate. However, most of these studies were conducted in highly specialized centers. The present study was designed to compare the short-term results of Stapler hemorrhoidopexy with Milligan-Morgan Hemorrhoidectomy.  (2007) reported findings of shorter hospital stay in patients undergoing Stapler hemorrhoidopexy (weighted mean difference, -1.07 days; P = 0.0004 (15).

Recovery Days:
In our study When comparing time taken for return to work in days in two groups of patients, a mean of 7.55 days in the Stapler group and 12.