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Functional and Structural Abnormalities After Milligan Hemorrhoidectomy: A Comparison With Healthy Subjects

Johannsson, Helgi Örn M.D., Ph.D.1; Påhlman, Lars M.D., Ph.D.2; Graf, Wilhelm M.D., Ph.D.2

Diseases of the Colon & Rectum: July 2013 - Volume 56 - Issue 7 - p 903–908
doi: 10.1097/DCR.0b013e31828deb6d
Original Contributions: Anorectal Disease

BACKGROUND: Fecal incontinence is a rare but well-known adverse effect of hemorrhoidectomy.

OBJECTIVE: The objective of this study was to identify possible reasons for incontinence after hemorrhoidectomy.

DESIGN: We conducted a retrospective comparative study.

SETTINGS: The study was performed in 1 university hospital and 1 general district hospital serving 2 counties in central Sweden.

PATIENTS: In a cohort of 418 patients with consecutive Milligan hemorrhoidectomies, 40 reported fecal incontinence that was attributed to surgery. Of these, 19 patients agreed to participate. Fifteen age- and sex-matched patients from the same cohort who were operated on, but without symptoms of incontinence, were also studied, as was a third reference group of 19 age- and sex-matched persons serving as a population-based control group.

INTERVENTION: All of the participants answered a bowel function questionnaire and underwent clinical evaluation, including rectoscopy, anal manometry, saline infusion test, and endoanal ultrasound.

MAIN OUTCOME MEASURES: We evaluated anal resting and squeeze pressures, sphincter defects, and continence function.

RESULTS: The symptomatic patients had higher incontinence scores than the control groups (p = 0.00002). The mean resting pressure at the high-pressure zone was also reduced in this group (p = 0.047). External sphincter injuries were detected in 4 (20%) of 19 subjects compared with none in the control group (p = 0.11). Saline infusion test in the patients reporting incontinence showed reduced ability to hold liquids compared with healthy controls (p = 0.004).

LIMITATIONS: This study was limited by selection bias and limited numbers in the groups.

CONCLUSIONS: In the group of patients reporting incontinence after hemorrhoidectomy, there was a proportion with sphincter defects and impaired sphincter function. These results indicate a need for cautious patient selection and improved or alternative surgical techniques.

1 Department of Surgery, Falu Central Hospital, Center for Clinical Research, Falun, Sweden

2 Institution of Surgical Sciences, Department of Surgery, Uppsala University, Uppsala, Sweden

Funding/Support: This study was supported by the Center for Clinical Research (Dalarna, Sweden) and by the Swedish Research Council, project No. K2000-27X-13082-02B.

Financial Disclosure: Wilhelm Graf has received reimbursement for traveling expenses from Oceana therapeutics.

Correspondence: Wilhelm Graf, M.D., Ph.D., Department of Surgery, Akademiska Sjukhuset, Uppsala, Sweden 75185.

© 2013 The American Society of Colon and Rectal Surgeons