NICE Technology Appraisal on Stapled Haemorrhoidopexy for the Treatment of Haemorrhoids

This article outlines the recommendations, the clinical and cost-effectiveness evidence and the Appraisal Committee's considerations for the recently published NICE technology appraisal on stapled haemorrhoidopexy for the treatment of haemorrhoids.1 Estimates of the proportion of the UK population affected by haemorrhoids range from 4.4–24.5%. In 2004–2005, approximately 23,000 procedures listed as ‘main operations on haemorrhoids’” were performed in England and Wales. Haemorrhoids are classified as ‘first-degree’ if they bleed but do not prolapse; second-degree haemorrhoids prolapse during bowel movements, and reduce spontaneously; third-degree haemorrhoids prolapse on straining and require manual reduction; fourth-degree haemorrhoids prolapse and cannot be manually reduced. Surgery is the usual treatment for third and fourth degree haemorrhoids that have not responded to non-surgical interventions and for full circumferential second degree haemorrhoids. The most commonly conducted surgical techniques are the Milligan–Morgan or Ferguson haemorrhoidectomy. The Milligan–Morgan procedure involves dissection of the haemorrhoid and ligation of the vascular pedicle with the wounds being left open to heal naturally. Healing is frequently delayed, which may result in discomfort and prolonged postoperative morbidity. The Ferguson procedure is a modified version of the Milligan–Morgan technique, in which the wound is closed with a continuous suture to promote healing. Another, less frequently used procedure is the Parks submucosal haemorrhoidectomy, which uses intra-anal incisions directly over each haemorrhoid, with the underlying haemorrhoidal tissue excised. Stapled haemorrhoidopexy is a technique that reduces the prolapse of haemorrhoidal tissue by excising a band of the prolapsed anal mucosal membrane above the dentate line, using a specially designed circular stapling device. This interrupts the blood supply to the haemorrhoids and reduces the potential for available rectal mucosa to prolapse. Stapled haemorrhoidopexy has been carried out in the UK for the last 2–3 years.